HomeMy WebLinkAbout1269A WORKERS'COMPENSATION DECIARAflON . � .
I hereby affirm that I have a ceNificote of cansent ro self `j�
insure,or a certificate of Workers'Compensation Insumnce,or ]bA647D LS
a cartified co y fhereof(Sea 3000,Lab C.) CEBPB�REV,B/81) APPUCATION �QR PERMIT
Polity NWP�5,32..L��a�rFremont Indemnity . �. .
❑Certificd topy is hereby fumished. SEWER - SEWAGE DISPGISAL, �
�Ce�}rf�'a��copp}�c filed w�th the�,�p��qty I ing inspecrio COUNTY OF 40S ANGELES BUILDING ANQ 3APETY
deb6FirhEt�Y.�v AI.iC. �� � 1 � 53�� � .
Dote Applicant' b���- FOR APPUCANT TO FILL IN � CONNECTION OATA
CERTIFICATE OF EXEMPTION FROM WORKERS' evuow� �` 'tOS sTanoN aePrH
COMPENSATION INSURANCE nooaess
(This seclion need not 6e tompleled if ihe wo�k involved by the �OCAUTYLIZaIROTld i.l`c�.Y N'ANHOLE REFERENCE � UPPER
permit is for one hundred dollars($100)or less.) iowee
I certity ihat i� the performonce of the work for which this ceossss rvxoFcorvHeaioN .
,Go den Springs Carpio �N�THFa�M
�� CURB P.L M.LTOP.L.
permit is issued,I shall not employ pny person in any manner P�No J
so os to becoma subject to the Workers'Compensation Laws. owNea CO.�MP.NO. J06 NO. ��J�
��� TRUNKPERMITNO. ROA�PERMIiNO.
ADDRESS
p�e Applicant � T. aFFionvir WANER EASEMENT RECORD.MSTR.NO. DATE
� TICE TO APPLICANT: If, after making this Certifimte of ��Ty (�'OV1T1S ,R. 67-9541
__,ornp�ioo, you should become subject to the Workers' LEGAL �
CompensaHon provisions of the Lobor mde,you must forthwith oescRivrion � �O. HWY.ON ST.WIDENING
comply with such provisions or this permil sholl be deemed
f2VOked. B'.00K i CT STATE ENCROACHMENi
UCENSED CONTRACTORS DECLARATION .oF etocs. veaMir No.
SIZEOFLOT W ON LOT
I hereby offirm that I am licensed onder provisions of Chapter �sE o� -
9(wmmencing wilh Section 7000)of Division 3 of the Busi- euuoiN�s CHnaGes
ness and Professions Code,and my license is in full force and /+ T -
CffeC1. � �OMRACTOR R.l.�.R. P lumb ing� 1n C. CONNECTION CHARGE FEE �
litenseNumber_ 33G�i�LB u�.cio,s � C-36 qDDRE55 � REIMBURSEMENTFEE �
p p` 0
RCR P I.ilIIll]121�fe O/1 4/V V OISTRICi NO. GROUP MAP PROCESSED BV V
Coniroctor . . . CiT . - TEl.wO � BN PG Z
❑I om exempf under Sec. of ihe L.A.Co. uCENSe No. • Ci 55 _ �� o
NO. DESCRIPrIONOFWORK FEE
PlumbingCadeand/orSec. ofthe � FirvAi �J
HOUSESEWERCONNECTINGTO �_. DAiE VqLIDATON d
B.R P.Code for the following reason aUeuC SEwEa �� �� N
SEPTIC TANK.$EECAGE PIT OR FlNAI �
PIiS AN�/OR DRAiNflEID
Ddte � HOUSE SEWER CONNKTING i0 BY
GRIVATE�ISPOSAL SYSTEM
$ignature CpNNECI'ADDITIONAL BLOG.OR �
OWNER-BUILOER DECIARATION WORK TO HOUSE SEWER
�"'�reby affirm that I am ezempt from the Contractor's License exiNf��Ess ErooiGoevwE�iAMnivHoie
�for Ihe following reason(Setfon 7031.5,Buisness and Pro- ureu,aevniR OR nennloonl HOUSE
inssions Code): SEWEa oR Di5PO5Al5r5TEM
❑I,as owner of rhe properry,or my employees with wages as �.� .� 2� C.�,
iheir sole compensation,will do the work and 1he structure �
is not inlanded or offered for sole(Settion 7044,Business
and Protessions Code). OWN6R'S Permit g �/��f �:� ° '� � �
❑I,as owner of the property,am exdusively mntracting with AUTHORIZATION TOTAL PEE � :,c�f,����
licensed coniractors to consiruct fhe projetf(SeClion]�4Q, �HpyE qT THIS DAiE A CONTRACT WITH THE HEREIN NAMEO CONTRqCTOk TO
BusinBss pnd Pro{CSsiOn3 Code�. CONNECT THF A60VE DESCRIBEO E%ISTiNG DWELLING TO THE PI/BLIC SEWER. M� ; �''/..`;,;�
CONSTRUCTION LENDING AGENCY � - ► �
I hereby affirm that there is a consiruction lending agency SIGNEDTHIS DAYOF Iq,_ �i,2 G,.,`�
for the performonce of the work for which ihls permit is �'NER OR
issued(Sec 3097,Civ.C.). owNEzs n�eN*
Lender's Name ADDRE55
lander's Addreas �
I certify that I have read this application and state ihar the
above informatio�is correct I agree to comply wiih oll Counry �
ordinances and State laws regulating Plumbing and Sewars, ���
and hareby aut orize representatives of�his County to enler � .
upon ihe abov entioned pr erty for inspaclion purposes.
RCR By: �����8/14/86
Signoture of Permitiee Date SEE REVFRSE FOR EXPtANATORY LANGUAGE
-' ���� . ' � � ' � -���}�`� r � � �� _� r � ■�''�' � � ' ��
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� ' � e � il - S. ��-� a . _rt �.
iNsrEtrotts NOTEs OWNER-BITII.I7ER HEC�,ARATION
APTIFOVA�,$ �^TE ��T�s��� � I het¢�y affi:s�t�aa I etv ezeeapt fraa�tke Contzaeto:'s
NEW HOUSE SEW44 Licer.s:La�a fot the fo2Sov:inR res�un(Sectior. 7D31.5.
�r�°-� � - � Betsdtress�a.:�'Profesro�s Co:��/:t.;�y ciSy or ma�ty
.cpran[ernaorior�a.i . - � � � - wbicb rag�fra;a p�n:;ia tu ronsY;�:ct, alfar, im�rrsve,
BUILDING OR W'OFK . �ppJ(ffq�CC fl��ff G'.8�'SSHie.""INNPCr�iCt tC i1S ifdMmMCQ�
�ioR oRAi�ioi(s) . alta swQs�drvs tbr aj26liou�t Jor sxb¢or�si? tu fi� a
CE55iOp.❑ oreYwFu� . sigwB�d sMfsMiw�PbaO M is/isbwsad peiraa:ortd M ibe
prouawss of tbi CaetYrcia✓s Liciwea I.a/:�/CbepWl'4
qTER.REPAIR.�R OP. (c�cirg wieb S+cewa� 708U)oJ Diwixiva 3 oj t�e
SEYdAGE D15705h1 SVS'.EM �
DISCONNER VIUG APq � � ��aWl�PYV�fBftYOMi Cala)or iha[br ir eznnc�t
ABANDCIJ HOUSF.SEWER �.,��y�rem and�b�r b�cr',-jor tb�r alkysJ ex�pa:oR.A�y
a.�ie�sFrn€r�s❑ ui�luAieet a�fSa�Yi�aa 7Q31.S l�j'aeY ap�6�T+'e'wt jer aparmit
sc�R.wr s�O ces.sroas � subjucta tba apylicsrt Lo a ctiviil�T+�+r�v af++et enar�e tbwr
ftva br�dta�do!lars/.$506¢:
.. . . . �t,e�the rnvser oi t1�e prapc�ety w�tl do tLe w�' vud
- � � � t6e struanc�is ao:III:c'Gd&'S QP OI�C'LEd It7f B6olm•
�YG. 7�t4� BfKf7iJ83 OMd�%OMS r.Or�li 7'�Jf r.O1F-
. .. � �lAC�Ol�S L�EMfY�9W dPii 1fOF(�t i0 YOF OlYfli�Of
. pY[I�YPbj'W11D r1if1�7jY OC%p/�iI6HBi�'I6N,6Mi�tfl�AOlfU�F
' Si1C�/1WM� �bYKPi�p'M�6gY,�1��,� �fOP 9W'�1 %Mf�f�IM1E
OIi 1fOi sliPOl1�*+.�W.7re.w�SA�tl.J�11'BIHCOBf� EbB
� � �Y%�%f�'O�f�llbfl{�IfiM6 li SO�`1JI��ilf OM'y80L'Of
. .. . ObW�/w)M� �f OfUifii'•�Y[�M' 1��)Mi� T�W �IMWjVM
. ' . . . . Of�Z(JS(�li�fstif bN{�Gf 1MQ1'OV!j0/�i
Pn+�pans of+dal
I affi exta�pt uandtr Spe. ,
B&P.C.fior thi:rees�cm
Bate
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INSP�CTBR'g NOTB