HomeMy WebLinkAbout1272A WORKERS'COMPENSATION DECLARATION - �
I here6y affirm that I have a ceriifiwre of co�sent to self .
insure,or o certificate of Workers'Compensation Insuronce,or �aneeso
a�e��,f�a�o�Y6�a�e�f.��3�,,Lab C.) y �foe IRev Biei) qpp�ICATIQN FC�R PERMIT
Volicy N a„Y remont Iizdemnit
❑Certifiad copy is hereby fumished. SEWER - SEWAGE DISPOSAL �
❑Certified copy is filed wi�h ihe county build' g inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
X department. '
Date R��1/�/A�b4pplicanl p�R���. � FOR APPLICANT TO F1LL IN CONNECTION DATA
� - CERTIFICATE OF EXEMPTION FROM WORKERS' au�ioiN� � 5Tn*ioN oer�n
� COMPENSATION INSURANCE nooaess
(This section need not be completed if the work involvad by the ��i�TY � � nw.NMo�e eeFeueNce aWE q
permit is for one hundred dollars(5100)or less.)
1 cerrify that in rhe performance of the work for which ihis cRosssr Tr�oFcoNNeaioN LENGTHFROM
V. CIIRB P.L. M.l.TO P.l.
permit is issued,I shall nof employ any person in ony manner P�� a/�
sa as ro become subjec�to the Workers'Compensa�ion Laws. owNee co.iMv.No, �os No.
��� iRUNN PERMIT NO. ROAD PERMIT NO.
Date Applicont Aooue55 Parkview� Dr. /�
�'TICE TO APPLICANT: If, after making ih15 Cerfificale Of ��TY �Q\Jln'a, -��""M. 9�7�95y1 � �+fFIDAVIT WAiVER FASEMENT RECORD.INSTR.NO. DATE
mption, you should become svbject to rhe Workers' �EGa�
Compensation provisions of the labor code,you must forthwilh� oeseeivtiON � � o, � Hwv.oe sr.wioeNiNe
comply with such provisions or this permit shall be deemed
revoked. � siocK T CT STATE ENGROACHMENT
� LICENSE�CONTRACiORS DECLARATION ,or eiocs. PERMir NO.
SIZE OF l07 �� NOW ON LOT
I hereby affirm thot I am licensed under provisions of Chopter uSeOF
9(commencing with Section 7000)ot Division 3 of the BUSi- OVIIDINGS n 'al cNaeces
ness and Professions Code,and my license is in full force and
effect. coNTRncTOR�•C.�R. P umb ing, Ine. coNNecnoN anace ree y
license Number � ���_Lic Class�� qpDRESS ' REIMBtIRSEMENT FEE �
DISTRICT NO. GROUv MAP PkOCE55E0 BY V
Comracror RCR Pl nmhi nl�iie $,/�y�RFi ciTv . *e�.No j,� sK ae 2
❑I am exemp�under Sec. of rhe L.A.Co. iicENse No.� � cuss � �
V
NO. DESCRIPTION OF WORK FEE �
Plumbing Code and/or Sec. of the HOUSE SEWER CONNECTING TO / DA E` 'J VAUDATION d
IPUBUCSFWER / `� /�` y �
B.8 P.Code for the following reason SEPTIC TANK,$EEPAGE PIT OR FINAL ?
PITS ANp/OR DRpINF1ElD
Date MOUSE Sf WER CONNECT�ryG Tp Bv
PHIVPTE�IS�DSAI SYSTEM
$igna�Ur9 CONNECT ADDITIONAL BLDG.OR ,
OWNER-BUILDER DECLARATION WORK i0 HOLISE SEWER
I�J.iereby affirm ihot I am exempt from the Contmctor's License ��rNF��EsSvooiGoa�rwEiRAnn.aNHo�e
. for ihe fallowing reason(SeCton 7031.5,8Ui5n255 and P�o- ALTER,REPAIR OR ABAN�ON NOUSE n
.lons COdeJ: SEWER OR DISPOSAL SVSiFM . � � L`7�C t1
❑I,as owner of ihe property,or my employees with wages as � � .� Q
iheir sole compensaiion,will do the work and the strocture f��° e �
is not intended or offered for sale(Section 7044,Business
ond Profess�ons Coda). OWNER'S Permit y c'"�� I � � �7,�('i
❑ I,as owner of the property,am exclusively mntracting with AUTHORI2ATION TOTAL FEE � r; Q�, �, `�s
�IC¢fI6Ed coMractors to tonstruct�he project(Sec�ion�Q44, I HAVE AT iH15 DATE A CONiRACT WITM THE HEREIN NAMEO CONTRA(,TOR t0 � ��� ��
BUSi�855 OI1C)PfOfB5510/15 COCIC�. CONNECT TME AB�VE DESCRIBED EXISTING DWELIING i0 THE PUBIIC SEWER. �,r,n j��L
CONSTRUCiION LENDING AGENCY - �` � � �
I hereby affirm ihat there is a consfruction lending agency SICaNEDTHIS DAYpF 19_ ►
for the performance of the work for which th�s permit is °'+�'�EpoR
OWNERS qGEN'
issued(Sec.3097,Civ.C.), qoouess
lender's Name
lander's Rddress �
I certify thaf I have read this application and state tha�the
abova information is mrrect.I a9ree to comply with all County -. . ,
� ordinances and Stafe laws reguloting Plumbing ond Sewars, � �
ond hareby authorize representotives of this County�o enter � . �
��. Upon ihe obov eMioned pro ty for inspecfion purposes.
RCR By:����/14/86
SignatureofPermitlae Date SFEREYERSEFOREItPLANATORYIANGUAGF
�
�
�� � ��i � ����� "`�.
nasvEcroxs nor�s OWNER-B�lII.T3ER H�CLARATI�iV
_ APPROVAl.S �A� ������ I here6y sEfir�n thot I am aacesEpc from the Co�xiractor's
r+Ew House scwea �„�2 � Licens_Leww for the fntlor.�in�;-rea�scn(Sertior.7031.5,
Btuiaaess ar.�d Profcrst�r.�, Codsl:Any ci:y or musry
NNNCCTAODITIONAL sybiab r uirer a cr,it eo w:�s[rract,e16e.-.i ove,
BUIIDiNG OR WORK . '- dypNpJ�F(K Of f$��pfi�,'gM`ME'�y pyjyy tp six irrrrwca,
�ioeNovAi�iior�s� a�o r.grtnre tba e�yp�eat jnr snsh pen»:a ro jrk a
sigaxl statascat tLoai ba is lisswsa.'gwsw�aF t� tba
eessroo�O aew�u❑ . . pronisians g/tbr Cosiiaasetar's t,i.w�uscr Lsrr(.i,bqpar 9
0
's�v�r,c�o��s�ss,.c�°s s�r � /rom+w�cirr8 wifh Seceian 7400/af Diviyrox 3 oI tbe
B�usi�rs mrd R�o�/'�rsiar: Gedryl or tii�at 6�ir axwnpi
� °�Hoi�se�ro a . . . � tbav�efnem.,o!�rd tL•u bmie Jor yed�r�s a71�9+���+Lf���An3+
&4€f(fRi5fFT1ETANKSCI , . . . LIDJO{�DN.yS/BjI6NI��1.S'?��J�aP�t
5eE+,vr� .❑ Ceeerez�ki � aklyeeu tbe a¢pTitar.t to a ciai:peRalty of nas nrore t$qs
_ , . • . fiw ba�dr.d Jalierr(i39f!#.:
. � �I,ec the oR�ner a£t6e propertY Q.iu do the wa-`-aad
. . . xhe attuctore i�not intendr,d or adf�sd fus eate:
/Sec. 7044, Ep.sba«cs a+d Pscfe�iau Cada Tlsr Co»�
G�aMur�'s Lienavr Lr+dors+�oi qpyly tn ae u�wur eJ
. property wbo buildr orl1uu�raa:ss tbxeaq,ad mba doas
� rurL s�aor�6�n�t]7�drf tLa/.+a�i�n�s
. oIr»ot 1»EeMdid or o�r�ud for saln.7f,F..aawiw[',iAc
. . L�uiLfiyg or�t ir+old�+adi�6iw una Y�'A�
� cau0l+Oiow, tbs owwrr�b+wld�r tuilF baw fLe d�wdrw
- � � oJ proniqg t�6a�be did w++t briJd ar kmr�oe�s�6or tbr
Ay�+�af aak.1
I a,m exempt uiadnn Sec. ,
B&P.C.far this resaoia
, • Date
�
ir�tfo+�s No�s