HomeMy WebLinkAbout1273A WfiRKEQ3'CUMPENSATION UECLARRPION � � � �
I hereby affirm �hat I have a certifimte of consent �o self
insore,or a certifiaate of Workers'Compensation Insurante,or �enanzo .
acertifi��,���,���.3�����t Indemnity ��B�REV.B/81) ' �i pp�ICATIGIN FOR PERMIT
Policy N . o pany , �
❑Certified copy is hereby fomished. � SEWER - SEWAGE DISPOSAL .
Certif�ed copy�s filed with ihe county buildi���999 inspection COUNTY OF LOS ANGEIES BUIL�ING AND SAFETY
�departmenf. � O��
Dare�f 1 4/86Applicant RCR $}T• �'� � FOR APPLICANT T4 FILL IN CfJNNECTION DATA
�� CERTIFICATE OF EXEMP710N FROM WORKERS' eunoiNc `/� sTnrioN . oePTH
COMPENSATION INSURANCE nooeess 7- ]� �
(This sec�ion need no�be comple�ed if the work invo�ved 6y the r,wNrro�E REFEaENCE uPPER
permi�is for one hundred dollars(5700)or less.) �ocnuTv towee
I certify ihat in the performance of rhe work for which this cuossst 1 Y''n C Y� 10 TraEOFcoNNecnoN t�rv�TMFgpM
permit is issued,I sholl not employ any penon in any manner Y. CURB P.L. M.L.TO P.L.
so as to become subject to the Workers'Compensation Laws. r.c.No. /
OWNER CO.IMP.NO. JOB NO. (��I�
�'�� TRl1NN PERMIi NO. ROAD PERMI7 NO.
Date ApplimM � npoR[5s ������
r"�71,CE TO�APPLICANT: If, after makin �hi5 Ceffl}i[aI2 Of AFFIDAVIT WAIYER fP.SEMENi RECORD.WSTR.NO. DATE
� 9 CIiV ��-tEL�.NO _
lhption, you should become subject to ihe Workers' �E�ai '
Compensation provisions of the Labor coda,you must fo�thwith �sceiaTioN �or100. nwv.oa si.wiaeNiNc
tomply with such provisions or this permit shall be deemed .
IBVOkB(I. BL04K i�CT 57ATEENCROACHMENi
��.OF BLOGS. PfRMIT NO.
IICENSED CONTRACTORS OECLARATION SiZE Or LOi ': ' - ��"� NOw oN iOt
I hereby affirm ihat 1 am licensed under provisions of Chpptar u5E OF
9(commenting with Section 7000)of Division 3 of the BUSi- BWLOINGS Residential cHnaces
ness and Professions Code,and my license is in full force and � '� �1Tlg T1C.
effeCt. GONiRACTOR � � � ' i CONNECTION CHARGE FEE }
L�censeNumber��LIC.'C�a55 r:_'�h qpDRE55 12785� Ma nolia. Ave. REIMBURSEMENTfEE Q
Con11a[tOrRCR Plumbin�,e 8/14/86 ��TyRiverside � ,E,.No371-50�0 DISTRIG7N0. GROUP MAP PROCESSEDBY V
BK PG Z
❑I am exempl under Sec. of ihe L.A.Co. uCeNS[NO. C1n55 � �� �
NO. DESCRIP�IONOf WORK f{E
Plumbing Code and/or Sec. of the pinai w
HOU5E5E•NERCONNECfINGiO •� DAiE -7 VAItDATION p,
B.8 P.Cade for ihe following reasan � Pueu[sewea / � �/ y
. SEVTIC TANK,SEEPAGE Pii OR FINAI �
PITS AND/pR DRAINFIE:D �
Da12 FIJUSE SEWER CONNECTING TO BY
Si nO�ure 7RIVATE�ISPOSAI SVS7EM � � � �•��A
9 CONNECT A�DITIONAL BLOG.OR
WORN TO HOUSE SEWER •,�� o � C�
OWNER-BUILDER DECLARATION r7
OVERFLOW SEEPAGE VIT,DRAINFiEID �
',hereby affirm rhat I am exempr from the Contracior's License EXiN.,CESSCOOL,ORYWEII,MANHOLE ,
POf iF12 fOIlOwinc��COSOII(SBC7011 7O31.S,BUI50055 OnC�Pf0- AtTER,REPAIR OR ABANDON HOUSE ,' f, .,L'j,���
�ions Code�: SEWER OR DISPOSAL SVS7EM
❑I,as owner of fhe property,or my employees wilh woges os ° `- G L J�e c=i
fheir sale compensation,will do the work and Ihe struc�ure � � ���
is not intended or offered for sale(Sec�ion 704A,Bvsiness fl�i,�S
and Professions Code). OWNER'S Permit 5 fQ p
❑I,os owner of the property,am exclusively coniracfing with AUTHORIZA?ION TOTAI FEE `�) �
licensed coMroctors to tonstruct the project(Section 7044, i HAVE AT THIS OATE A CONTRACt WITH TME HEREIM NAM[0 CONiRACiOR TO
BUSIn253 antJ PIOfeS5ior15 Co[Ie). CONNECT TNE A80VE DESCRIBED E%ISTING DWELLING 10 THE PUBJC SEWER.
CONSTRUCTION LENDING AGENCY ' ,
I hereby affirm �hat there is a const�uction lending agen[y SIGNEDTHIS OAVOF 19_
far the performpnce of the work for which this permit is owNEkOR
OWNERS AGENi
iSSUCf�($BC.�7,�IV,�.�.
ADDRE55
Lender's Nome
Lender's Address � ��
�certify ihat I have read this application and siate that the
obove information is correct.I ogree to comply with all County - �
ordinances and SIa1e laws regularing Plumbing and Sewers, �
ond hereby outhorize represematives of this County to enter
upon�he abov �entioned ro fy for inspeefion purposes. �
RCR By:� 1�_ � /14/86
SignaFure o�rminee Dale SFE REVlRSE FOR EXPIANATORN UN4UAGF
�� .,
{ ����� �������� ' + ,�Y ��
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iNsvEcrorrs rimEs 138CLAR�tT�1�
APPROYALS ��� �r+yncrcx�s s�n,wwiu 1 nereby aHirm d�ae I am eumpt from the Co�aaor'.
Liceaee I.aw for thc foliowing:eamn/SeeNaw 7031.3,
NEW HWSE SFNER r..'_ � ' B43tMCfs wid PFoJeasiaws CodeJ:Awy ciiy or cou»ty
lIRONK10t WORKu � � 1Vb(C�J fBQYfl6i 6 pIY/Y11%i A�MNi{pWCfr O���I/pfDAir
�� ��) - �eMO(�S6i�M'/�pIW�',�Jq7rLYSf��Oi'b�f�AffQRLtls
Cco a1+o +rqrirrs !Ge�t far�b�t m jtk a
cpatva❑ orswiw❑ s'g�ad statesnu t6as 6r it Nanrfrd pr�a ro eba
� pro�sio«s nI tba GaeRteacior'i T.inbts I�nu�CLa�rter 9
��t�►�� (mronrNats�lr�wlt6 S�7�00)�D/ohioM 3 af tbr
Bwinecc�Frojeq}a�e Codt�w tbat b�Jt asn�rpt
r�sewu rberrfiani ard t!w bqitt far tbe olf�gsd asrmplias.A�y
ew¢uu s p wotntiaa of Src4los 7031.f 6,y�tloraparnli
affr Q �avoass❑ subj�ca sba appltwme m w cMtt oj�oe nrore tl�
jtv.6s�+wd do!!as ffT00�:
O I,es the mcner o[che wlll do tLewo�b and
the ssractme is nat in �ufLered f�a4�:
(Soc. 7D44,Bwtlren asd��Code+ 75r-Car
Nncror:/.icdae[�rw dors+wt�y oo�o�er aj
proparty wbo bwlaTi orin�roc�e t6_pwn,ssd eobo Joa
aurb warw binsrl,/fnonid�d tbal srcb l��eprourn��nq
are aot iaiaeded or o,/ferwct Jor sak.{L bnrcaorr,tb�
... . . d�ildls��ar l�rpraaawe�i�!t ml�aetibk�oM�'asr'of
co�pkr�, the auwH��6YfTdM+wYJ LQOit ileo isfdnt
uf'prouiMq ebst be dld wot 6wl�d or kupeow jor tlw
P+���f+�l
I��emgo�S�. - -- .
B 8c P.C.for thiC t�satt,
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Oaonr�r
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