HomeMy WebLinkAbout1270A - N DECLARATION r,�
I hereby affirm ihof I have a certifimte of mnsent to salf . �I
insure,or a cartificate of Workers'Compensation Insurance,or �aaa<ao . ZS
a ce�tified co iheraof Sec 3800,Lob C.) �ceeoe�aev.s.�e�� APPLICATION FOR PERMIT
Pai��Y NLdP��321��,a„YFremont Indemnity �,
❑Certified copy is ha�eby fvrnished. SEWER • SEWAGE DISPOSAL
❑Cerrfied copy is filed with rhe county 6utl {ng inspection 530/ �, GOUNTY OF LOS ANGELES BUILDING AND SAFETY
X depariment. �
Dote��,.(�,�$,�Applicom FOR APPIICANT TO FILI M CONNECTION DATA
� CERTIFICA7E OF EXEMPTION FROM WORKERS' euimwcLr Sipno� , o�e�H
COMPENSATION INSURANCE aooaess -r(�j � �tOS �
(This section nead not be comple�ed if Ihe work involved by the ,aA„TYDxamond- Bar M4NHQlE REFERENCE Ow R
permit is for one hundred dollars(5700�O!iezs.� . NEAREST Golden Springs Carp io N�EOFCpNNECTION �ENGTN fROM
I certify ihat in the performon�e of�he work far whith ihis cRosssi, r, cuRe v,�. M.t.rov.t.
permii is issued,I shall nm employ any person in ony manner v,c.No.
so os fo become subjact to fhe Worke�s'Compensolion Laws. owNER CO.IMY.NO. J00 N0. �d/�
��� � TRUNK PERMIi NO. ROAO PERMIT NO.� �
ppte Applicont a°oREu . P TI{.V�eW DT. /''
� i10E TO APPIICANT: If, offer making Ih15 Certifitale Of CIiV Cavina 67�9,5a{�, AFFIOAVIi WAIVER EASEMENT RECORD.INSiR.NO. OAiE
7EL."
..�mption, you should become subject to the Workers' �E�A�
Compensation provisions of ihe Lobor code,you must fonhwith oesceiPnoN � No. Hwr.oe sr.wioeNiNo
mmply wiih such provisians or ihis permit shall be deemed .
fEVOICBc�. BLOCK ACT .{�� STATE ENCROACHMENT
� LICENSED CONTRACTORS DECLARATION ,oF a�ocs. ffRMii No.
512EOf�OT � °� OW ON LpT
I he�eby affirm tha�I am licensad under provisions of Chapter u,E oF
9(mmmencing wi�h Section 7000)of Division 3 of the B�s�- euimiNcs 1 cHnac.�s '
ness and Profeuions Code,ond my license is in full force ond j� f� R T
Bff@C�. . CONTRACTOR•`"`�••`• Plumb ing� �inrr. CONNECTION CHARGE FEE Y
License Number� o �iC.��055�1� FEIMBURSEMENi FEE �
�'s-q-�r ��v nooaess O
CO�IfOCYOf�'��jly�atE ��Ii�� CITY . � iEL.NO.• DISTRiCT NO. GItOUV MAP PROCESSED BY V
--o BK PG 'j�� Z
❑i am axempt under Sec. of the L.A.Co. ucAEase No. � et�s _ `c. � / �
Plum6ing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE � FiNA� V
HOUSE SEWEIt CONNEC7ING TO �,�,_ �AiE VALIDATION y
PUBLfCSEWER � � � �
6.8 P.Code for ihe following reason s�anc TnNK,seeance rir ou vina� � �
PITS AND/OR ORAINFIELD
Da1e HOUSE SEWER CONNEC7ING i0 Bv
PRIVAiE DISPDSAL SYSTEM
Signalvre CONNEGT A�DIiIONAL BIDG.OR �
OWNER-BUILDER�ECLARATION woaKro�aouse sewea
!^`'��reby aftirm ihal I am exempt from the Conlratlar's License �iNF��cess EVOOiGoavsv��iAMnNHo�e
for the following�EOSOn(Secton 7031.5�BUISf1C55 ditd PfD- AITEft,REPPIR OR ABANDON HOUSE �
IeS510�5COCIE�: . SEWERORpI5PO5ALSVSTEM
❑I,os owner of the property,or my employees wifh wages as �..1 C�.G�
iheir sole compensation,will da the work and the siructure . #.„� s g � � C
is not in�ended or offered for sale(Section 7044,Business
and Professions Code). QWNER�S Permit 5 r� .��,�.����.•(.5�;
❑I,as owner of the property,am exclusively contrat�ing with A�ITMORIZATION T�T141 FEE � <' /
licensed controctors�o consiruct ihe p�oject(Section��4A, I HAVE AT THIS�ATE F CONiRACT WITH iHE HEREIN NqMEO CONTRACTOR i0 '� � "'(_` f:.��,i(Z,�,
BU51llESS tlfICI PfOTC5510l14 COCIf�. CONNECT TNE ABOVE pESCRIOEp EXiSTING OWEILING i0 iHE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY � , C!.�,�,i_�—cg E
� hereby affiim fhat there is a onslrucfion lending ogancy SIGNED THIS DAV OF � 19,_
ior the performance of ihe work for which this permit.is owNea oa .
i55uBd($¢c.3�97,CiV.C.�. OWNfRSNGENT
ADPRESS
Lender's Name
Lender's Address �
I cerfity�hat I have raod this applicofion ond state Ihat ihe _ � .
above information is cwrect.I ogree�o comply with all Counry . �
ordinoncas ond S�ate laws regulating PI�m6ing and Sewers,
and hereby authorize ropresentotives of fhis Counry to enter . - .
upon the� -�Red��for inspection purpases.
RCR B �;,� 8/14/86
Signafora of Permittae � Dafe SEE REVFRSb FOR F%PUNATORY LANGUAGF
�
�i.'�� ���c.� �. � � ? L �. � 4.. ' � ��L� � �.��� '� .
uasvecrae'�nore3 OWNt�it-BL7I�I78R P�B�A�ATDbN .y
APPROVALS ��TE in�Ta°`s s�u'� � I hera6y afiirm xhet I am eaemgt frsm tke Contcaetoc's
aew rwuse seweR p . Liceuae Law tez the following t�e3(Sacaiars 7031.5,
1 Flo li�. $tuinaac tmd Profcu%am Codc)- hery ctiDy r erxino9�
eowraeraociTioNai �� - wGick reguire.�a pr»,:it eo eoc�sir�ca,a1te.-,i>,;prove,
suucir�c ae woec �
�9!'�ic uau,s€cP.riifsl dl�olirb,or re�air aw�rOwrcir+mw.grior'6¢1K kawxcs.
n�ioR ww�Nr�e:� � aloo nqKiws tkre opplicent jur swcb pa»eit to fide a
�cfssvooi❑ � atvwc�t❑ - _ sigws,d awAnae»t ibai br is lirenred pwarorrt to tbe
A�'�4�t8s Caws.rsrtori IAcarWv I�u/C6qperr 9
�ata[a,a�vw�,sEvhw oa _ . . /cmnm�wcircg+xitb S+aeiaw 7GBf11�I�iedrraw 3 u1 tb.
SEWAGE OISCO�P:SYSiCf?.
. . . Brrrin�cc rsad Profursioxs Cod.J or thas be is arerwpt
os�oNec�cr au�nwa � .. . tbareJ+m�.arod tlw trurs firr�ibe olJsgwd axerwpaior�A+ay
�Nooni riousc sEweR
er� �sc�vf�e r+rP;Ks p � . o:alutia�x o9�Swi:ow 703I.5 by awv ayplkawa far aprr�vsit
s�P,wr 5 CI cEsS�:s � � srbjrcd ibe�p{dcant to a cie+idOe+s�d`t3"of+rmt mare thar
. ... � jfws bawd+wed dolfaes(�'SOf1J.r
. . � ❑I,as the wmes of the P�M�'�Y will da�the wr�__..�ad
. � ' . . the sanctuce ic not ini�ende�.or oLFered for sale.
� /Sec. 7044, .Bw'iuwa asd Ff�fssriurs CodeF Tbr�Car
� , Mutor's Lictrcr Lew duu�rat ap�6:gr sn w+�owKar of
� � p�epr►gr wbo Mti4tt er i�rovsa thereaw,a�dwbe does
� sarb wark birhsa�f pr�wid+d lbat swc6:i�nproves�ewis
a+a+wt urt�d/ed ae ofj�red fhe.tdr.I�Iseswrxr, eb�r
. . � 8nildiag or improne'uaxt ie snkl witfiia wrs Yonr of
� � - conrplrtiox. i8r�taifk lw�s�$s 6wdwc
. . .. , . . . oJ provisg�ebat bc did xot b+wtd or rmpro.w far eba
Ad+f�•9f�+/
I am exemgt nrnde�Se�. ,
B�P.C.for thi�re�a
Dste
Oa�aer
IFiSPECiOR'S NOTE3 . . ..
