HomeMy WebLinkAbout1247A WORKERS'COMPENSATION DKIARATION - - - � � � � - � � �� � � � �
I hereby affirm that I hove a cenificate of consent lo self
insure,or a certificate of Workers'Compensation Insurance,or �anea2o -
a certified copy thergof(Sec 9800,Lab C.) CE 80B(REY.8/81� APPLICATION FOR PERMIT
Policy NoT.'m�zC.��p�ny ��eB�.tY� T...—xxxnnim-lty @s
❑Certified copy is hereby fumishad. . � � SEWER - SEWAGE DISPOSAL .
[�Certified mpy is filed with the counry buil ing inspectia COUNTY OF LOS ANGElES BWIDiNG AND SAFETY
dep rts�F�t.
ome g�i6�$�.pplicaM RCR Sy: ' r PpR APPLICANT TO FILL IN CONNECTION C1ATA
CERTIFICATE OF EXEMPTION FROM WORKERS' euitoirv� 462 AY'Ill.l'COS Place STATION DEPTH
COMPENSATION INSURANCE A�ORE55
This section need not be com leted if�he work involved b the p �P�R
P Y LOCALITY DZ`a.IISOTLCl y`�.T M4NHOLEREFERENCE
LO`NEW
permit is for�one h�ndred dollors(E100)or less.)
I certify rhot in the performance of rhe work for which ihis ��SsST rvveoFcoNNeaioN �NcrNFRpm
Y. CURB P.L M.l.T0 7.L.
� permit is issued,I shall not employ any person in any manner
so as to become sub�ett to ihe Warkers'Com ensation lows. OLl Ci0 Tl Y .r..OY a c.No. 'j
� P OWNER P' CD.IMP.NO. JOBNO. b ��,J�..
'��� -• •� OX TRUNKPERMITNO, ROADPERMITNO.
Dr]}e APPIiCpflt � ADpFE55
r 'ICE TO APPLICANT: If, afler makin fh15 CCfti{iCafe Of 0 AFFIpAV1T WPNER EASEMENT RKORD.INSTR.NO. DATE
9 �,rY vina:, -R,, tsi8-96/-9541
-umplion, you shou�d become subjecf to the Workers' ��qi �� � �
Compensation provisions of the Lobor code,you must forthwith OESCRIMION �ot o. Hwv.oR sT.wioeNiN�
comply with such provisions or this permit shall be deemed
revoked. aiocK TR T STATE ENCROACHMEM
BlD . PERMiT NO,
LICENSED CONTRACTORS DECLARATION SIZEOFLOT �� ' NOW ON LOT
I hereby afflrm that I am licensed vnder provisions of Chapter use or
9(commentinq wi�h Section 7000)of Division 3 of the Busi- euiioiacs R Sd TLt1S1 CHqRGES
ness and Professions Code,and my litense is in full force and
� eTfeCl. (� t CONTRACTOR R,��R ' CONNECTION CNARGE FEE a
LicenseNumber 336428 �j� ��OSS ! "�`�� REIM6URS[MENTFEE Q
RCR PLIJMSI71��Yy� 6/lu' H6 ADpRESS 12 M 1 u
C011tfqtfOf uO�e ��ry Kiverside TE,.No./14-371-5U00 pISiRICTNO. GROUP M4P PROCESSEDBV
BK PG Z
s�a.e j q uc. l:— b G2S a
❑I am exempt under Sec. of the L.A.Co. ucENse Na. unss r
Plumbing Code and/or Sec. of Ihe ND. DESGRIPiION OF WORK FEE FINAL yj
! HOUSE SFWER CONNECTING TO /�'j �� DnTE � � //�' VALIDATION L
/ PUBLIC SEWER / / / a �
B.&P.Code for ihe following reason SeaTic i4rvK,SEEPnGe ait Ok FiNn�
vITS ANo:OR DRAINFlEID
DOtB HOUSE SEWER CONNECTING TO g�
PR�VATE DISPOSFL SYSTEM �
$i9natUl2 CONNECT ADDIiIONAL BIOG.OR �
OWNER-BUILDER DECLARATION wOeK TO nous�sewea
l""'�reby affirm that I am exempt from the Contractor's license oxtENF�oessaooiGoevwoeai�N��ro�E .
�for the fallowing reason�S2Cf0t1�O3I,S,BUISf1C55 dpCl Pf0- ALTER,RF9AIF OR ABANOQN HOl15E
iC55iOn5 COfJCJ: SEWER OF DISFOSAL SVSTEM
❑I,os owner of ihe properly,or my employees with wages as
their sole compensation,will do ihe work and ihe slructure :_..� +��,,�A
is not intended or offered for sale(Section 7044,Business
and Professions Coda). OWNER'S Pe�mit ; `U Q
❑I,as owner of ihe property,am exdusively contracting wirh AUTHORIZATION TOTA�FE� ��. �[� #` �{ ° �O 1 Q
licensed contraclors to consirucf the project(Settion 7044, i HAVE Ai iNiS DATE A CONTRACi WIiH THE HEREIN NAMED CONTRACiOR TO ��[ p������
B1151l1255 Of1d PlOfC551pfIS COdB�. CONNECt THE A60VE OESCRIBE�EXISiiNG OWELIING TOTHE Pl18LIC SFWEN.
CONSTRUCTION LENDING AGENCY � � .m r �. �%7 �'�;�
I here6y affirm Ihat ihere is a construction lending ogen[y SIGNEDTHIS - DAYOF 19_ `�
for ihe performance of ihe work for which ihis permit is owNea ae
issued(Sec.3097,Civ.C.j.
owNeas nce�r £�2 5�8 6
ADORE55
Lender's Name
Lender's Address � . ' �
I certify that I hove reod ihis application and state ihat ihe
above informqfion is correct.I pgree to comply wifh all Caunfy � �
ordinances and Sfafe laws regulofing Plumbing and Sewers, .
qnd here6y authorize representotives of ihis County to enter � - -
u�`R aBabove entioned pr��t'y�fiur inspac7ion purposes.
y`��� 1�- 6iibis6
� �� . R
Signature of Permittee Dote SfE REVERSE FOR E%PLANATORY LANGUAGE .
� � �" # �'��3 •�.� -• � e � -!�
� ' ,�' � �` � � � �
i �G�' � i �
���T°�HOh� OWNER Bi�IEDBlt DECL�iTiON
APPROVALS o^� ��T�'S�^T� I hereby e9fxm thac I am�appt feom tl�e Cmtracto�lc
�,�� ,� Licence Law for tbe fallowing rmon(Sscqon 703I.3,
� Bwisas ard Acfuaalosa Cadrk AsY�S' ��h
w�� $ - wbicb r�ys�vt a ps�rnii to c��atA+p ieiiP�'cve.
��darnaltrb.or++rJta�tr may smretsn.k�ior po t4/�wsrcr.
my
��.o�(s) . . a1m roq+yns f8e i fae ar�ir�ar�mit fo fU�o
�m
ct35aoo�❑ oerw��❑ sigrsd aeah��t !w a Hcruand prrn�wtt M tH
�4(tba CastesrA�r4 lhrer�Lru/C6qptn'9
'K (mnwwnrsM roitb S�ZQQO�of 1Nm6ioa 3 of tbs
Bnsinaa med FinJm�aat Cadt�m e�br it aynept
� �"� tbd+efiona mrd tln�Ju+t6r aQt�d�Atias.d+oy
�Sq .. . � . _ +ti�fAiosofSMel�i���2.fby. IO!'iPf�t
5�' �00�1 lqp�fk'Re tlTle�t t0 a CjD)/�J6O1 ��t/UOI'i t1lis
. . • • .. /•W�J9{I'f�iRd��0/J�f�jn'
❑I.B/TIIlOWo!lOftb! xlttd0-tk@N(�`9nd
the svuctnre ia na or a��p�.
fSen 7044.�aad su{o�t Coda� Tlta Cow
emctash Idn.�r�a/,�iu dns�+Aot to au o�Uitar qf
property wbo brild�w iisp�oc�s�nane,nd�nbo doos
. � � awdr wari,�nut�'pmal�d t1,M�,wa76 l�owninW
m+r�as�ttrdw3 or 9�urd lm aalr.�bnuu+tu, tbe
bnildl�g ar lap�aarm�si 4 mfd�uilblw ort J�'�
' coe+pledor, tbw omwmindtd�r wlll baor eEr 8a�drw
01 P�1►d tboa l�d!d wot bwild or Mrprow l�rbr
P�,�ol,.l../
t am earempt aadet Sec. ,
B&P.G far this�
Date
U�.n__Ex_
I�RPECTOR'S N07� �