HomeMy WebLinkAbout1271A WORKERS'COMPENSATION DKLARATION n
I hereby affirm that I hove a cenificare of consent �o salf _ II
insure,or o certifimte of$WLorkers'Compensation Insurance,or ianeezo JS
PolkyfN�°�Y6'�8��E6M¢any�TAIIIOTIC ITLUEICLTllty ��81REV.8/81) APPUCATION FOR PERMIT
❑Certified copy is haraby fumishad. , . SEWER - SEWAGE DISPQSAL
❑Cerrrfied copy�s filed with the rounty buildi inspection COUNTY OF lOS ANGELES BULiDING ANDiSAFETY
�' department. 'e �y .. .
Date��.$jApplicant hlk. �� FOR APPItCANT TO FILL IN CONNECTION DATA
� CERTIFICATE OF EXEMPTION fROM WORKERS' ewmiNc � srnrioiv � oevrH
COMPENSATION INSURANCE nooaess
(This section need not ba completed if fhe work invalved by the � ,•�pNMp�E REFEgpNCE uR'ER
permi�is for one h�ndred dollars($100)or less.) 10���'� �owea
NEAREST TVPE OF CONNECTION IENGTH FROM
I rertify rhat i� the performance of the work for which this ceoss sT. r NRB P.L. M.L.TO P.L.
permit is issoed,I shall not emp�ay any person in any manner P.�.N0. /
so os to become subject to the Workers'Compensation Lows. p�,,,NER CO.IMP.NO. JOB NO. O,� �G'
ADDRE55 e. en. roup TRUNK PERMIT NO. ROAD PERMIT NO.
A�le ApplicaM _'.
� 'ICE TO APPIICANT; If, affer makin 1hi5 Certificate Of ovina � �9 =9541 AFiIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DAiE
9 CITY � �TEL NO.
c.emption, you should become zubject to the Workers' �E�A�
Compensalion provisions of Ihe Labor code,you must forthwith oESCRivtioN lor HWv,oH ST.WIDENING
wmply with such provisions or�his permit shall be deemed
revoked. � siocK TR i $TATE ENCROACHMENT
- LICENSED CONTRACTORS DECIARATION ' .or e�ocs. reaMir No.
s¢e or�ot -�_� ow oN ior
I here6y affirm�hat I om licensed under provisions of Chapter use OF
9(commenting wilh Section 7000)of Division 3 of the Bosi- BURpiNGS Resident'al OinaGes
ness and Prafessions Code,and my license is in full force and �j
BffECf. CONTRACTOR R•C.R. i" umb ing� In.�.'. CONNECtION CHANGE IEE ',
a
License Number ']']�7IIG/�=Q_LiC,CIp55 ,�J� ADORE55 � ' REiMBURSEMENT FEE Q
co�na�+o�RC:R Pli�m}singr,�e l]J1�/(fh Rl,\TeX$1{ye TELN0�7���4�Q DISiRiCTNO GPOUG MHP �20CESSEDBV Z
CITY
STATE UC. BK tt"i
❑I am exempt under$ec. of Ihe l.A.Co. �i�Ns�iyp. �Ctnss C' `� �
H
NO. DESCRI7TION OF WORK FEF V
Plum6ingCodeand/orSec. ofthe / FiNAi � � �r7 VALID TION �
/ HDUSE SEWER CONNECTING i0 DATE
B.&P.Code for iha following reason vueucsewex y
SEPTIC TANK.SEEPAGE PIT OR FINAL ?
PITS AND�OR DRAIIJFIELO
Da�e HOUSE SEWER CONNECTING TO eY
PRIVATE DISPOSAL SYSTEM
Signature CONNECT A�DITIONAI 61�G.Oli � �
OWNER-BUILDER DECLARATION woae ro nouse SewFa
WERFIOW SEEPAGE PIT,DRAINFIEL�
/""sreby affirm ihat I am exempt from fhe Contractor's License exrN.,cessvoo�,oavweu,mnrvno�e .
�for the following reason(S2Cf011 7031.5,Bui5f1e53 Ond Pf0- ALTER,REPAIR OR ABANDON HOUSE �
TESSiOl15 COCIB�: SEWER OF DISPOSAL SYSTEM
❑I,os owner of�he propery,or my employees wi}h woges as `� 2 7.� H
thair sole compensation,will do the work and the structure f�m n d � � (1
is not INended or offered for sale(Section 7044,Business
and Professions Code). OWNER'S Permit F (.� .,�
❑I,os owner ot ihe property,am exclusively contracting with AUTHORIZATION TOTAL FEE � �'4'G �.5O
Iicensed contrattors to conshuct ihe project(Seciion��44, I HAVE AT THI$DAiE A fANiRACi WITH THE HEREIN NAME�CONTRACTOR TO s a "`�
Buslness and PloTessioni COd2�. CONNECT THE ABOYE DESCRIBED E%ISTING DWEILING TO THE PUBLIC SEWER. m t' �'"�'�'
CONSTRUCTION IENDING AGENCY � , ����;..�6
I hereby offirm thaf ihere is a cons7rucfion lending agency SiGNEDTHIS OAYOF 19_
for ihe performance of the work for which this permit is owNea Oa
OWNERS AGENT
issued(Sec.3097,Civ.C.). nooeess �
lender's Name
Lender's Address
I certify that I have read this applicafion and state ihat�he
. obove information is correct.I aqree fo comply wiih all Coonty .
ordinances and State laws regulating Plumbing and Sewers, �
and hereby authorize representotives of this County to enfer �
upon ihe abo mentioned pro erty for inspection purposes.
RCR By.��� /14/86
Signoture of Permittee Date SfE R@VERSE FOR EXPLANATORY LANGl1AGE
I
�� 1+ _ '+T� L • � _.i r t
i �� � Fi ��. � r����-� � �� ��1 I L � '� # �
�
� 3 , .!
#� _� � . * Li..� 4 1_ � ���� #�L
n�ctc�s wohs OW1�F�R B�7T�:D�D�i.��4TI�N
APPROVA�.S onse iweecr�rs sraaanacE t hereby aff,irnE tlr�t I u�exeffipt fma�the Coatreceor's
NEVJ HOUSE SENFR . t!„� F � . Licease Law fot the fallowin�rc.::�.oa/Scct:os:703I.S.
Bwalrcesa arr'Froje.rsior.s Co�:�/:�Sr,y ctty a cour,ty
�xNNECf�CIT�1�AL . ' L�IlIC�Fj��Tyf#jN9P83 6 1lYPHi[C t0 COYrSfiFNtT adter, iny�rove.
��s OP A�i�T tlMy 1FTYCEYI��flNX6P W fk'iPSY6ifL'E.
n�rio�oa°�oe"ni�ioT'S� al� »g�s t�?w�e Jaa sr�eb por.vicec ao fiJa a
sigaaf aWRerx�wt tbwr b,e is lkwuad(rrzrswanc£ta tbe
.cEsseooi❑ o�ttvweu p . . . py�.rivwr 4I 16a Contractr�rx Lerewfa Luu,�(Cbopter 9
�,�tr�rt,aert,iR.siwHt ort /earn�w�y w»tb S�eatid»70�t�1 of Di.risioR 3 oj tbe
SEWAGEDISPCSALSYSTfM �
qSCONNECf YU�MiB � BR911fYPf asd�Cod.�J or ek�t Iw!s acvaipt
nw�ooH r+ouse sexe{t � tberefians osd tSe baaic Jor tbc axhrgrd ex:rupt:aa.An.y
a�cKciu.s�k T.uacs p uiolrtion ay�Sce�703I.5 6y oa�q�ylhmrt,fer a pwmia
� SREv,vr�s�O [Essroots� � rndyeeU ai�e applrceut to a eizred p¢s�sl6y of xot nwn tibme
�.a,��rssoe�:
- ❑I�as the owa�r o€tne pe+�p�t�,vfBt ao tfie w, _Yssh
. - the atructvte iy nat int.:adud aa�o�+ed far sete.
. . � /Ssc. 7044, Harsirwn a�{Pf�fe�ioNs Crnda: Tb.�Core-
� ... . tnaeAv'r LirEaxe low dou xst�dy M ae nrvnsr of
prioperby�wb�n b�cdhis or 6�jbra�s theroan,wd wbo doec
sadr wor�l T�r!/'prne+rd�d tb�aaab b,y6saa«iwwds
. a�e rnr laoeitrt.d or ojjmsed Jw sak.If bvkwiw, tbe
- . bniddia�q or�pna�wae�Nt k aold witbirr o�ra yaar of
. cas�bfNutw tGs ovmav�E�-wilda wild Fraa� xLs brr.r.a+�
. . . . of pyouiieg i6ut l�did'»oe brciFd or inccpmwr fnr tlw
prrpasa of asir./
. . � � � . � 'I 9mt BXCOi�Utl�*$LNC. y
B�F`.C.fOt thiS tEasart
Date
f)acoet
INSR�TOICS NOTFS � .