HomeMy WebLinkAbout1244A WONKERS'C�MPENSATtON DECIAKl1TION �
I hereby affirm ihot 1 have a cartifimre of consent ro self
insure,or a certifimte of Workers'Compensotion Insuranca,or �enaaso
� o certifi� , ea� n �ab�., �EB��REv.e,g�, - APPLICATION �OR PERMIT
Volicy N �����1 � �remont Indemnity- �, e
❑Cer}ified copy is hereby furnished. SGWER - SEWAGE DISPOSAL
�]Certified co is filed with the county b Iding inspection COUNTY OF LOS ANGELES � BUILDING AND SAFETY
dekp�lr}(ytf'�6 RCR By }�
Date Applicanr ����,�dA��J p� FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' �iipirv�
� COMPENSATION INSURANCE � .nooeess � � p Pl sinnoN oerrH
(This senion need no�be tomple�ed if the work imolved by the �D18IDOi1Cl B$T ^ti°NHoiE aEFeRENCE i PwER
permi�is for one hundred dollors($100)or less.) ����'r
I certify ihai in �he performonce of Ihe work 4ar which this �qpsgssT, TVPEOFCONNECTION LENGTHFROM
permit is issued,I shall not employ any perspn in ony manner Y� NRB P.L M.l.iD P.L.
so as to became sub"ect ro rhe Workeri Com ensation Laws. P���NO�
� p OWNER CO.�MP.NO. JOB NO. �O
��� TRUMK PERMIi NO. 2�A0 PERMIT NO. '
DRte Applicant nooaess P,Q, pX- 3L
�' , . AFFIDAVIT WANER EASEMENt RECOR�.INSiR.NO. DATE
fICE TO APPLICANT: If, after making this Certifimte of Gtv C.OVlIId:;%"reL'. $�.$'y67-95�i1
�...emption, you should bewme su6ject to Fhe Workers' �GA�
Compensation provisions of fhe Labor code,you must forthwilh DESGRIPfION lOi o. HWv.oa 57,wioENwG
comply wi+h such provlsions or lhis permlf sholl be deemed
revoked. s�OCK �R SiATE ENCROACHMENT
BL PERMIT NO.
LICENSED CQNTRACTORS DECLARATION srze OF i01 w pN�07
I hereby offirm that I om�limnsed vnder provisions of Chapter use oF
9(commencing wNh�Secfion 7000)of Division 3 of the Busi- gw�DiniGS CHAaGEs
ness and ProfessionsCode,and my license is in tull force and T
BffECf. � CONiRACTOR R�C..R. P lumh ing a 1ILC CONNECTION CMARGE fEE r
LiC2nse Numbe�_'3.'1 L�_�ic.C�O55 !� REIMBURSEMENT iEE �
—Q—�� ADORE55 Q
Cof11fOC�Of���}l PT.ITMRTNQate jf 1 h/Hh �„Y Riverside � TE�.No714-:i71-5000 DISTRICiNO. GROUF MAG PROCESSEDBV V
8K PG Z
❑Iamexemptunder5ec. � ofihel.A,Co. uCNseNo. j64LH ��ASS C-36 � � �r
PlumbingCodeond/orSac. ofihe No. DESCRIPTIONOFN'ORK FEE FiNa� `j
/7 -..— ��/y��'6 VALIDATION y"',
HOUSE SEWER NNNECfING TO DAiE
PU6l1C SEWER
B.&P.Coda for the following reoson ypT�[TqNK,SEEPAGE GIi OR FINAL �
PITS AN�/OR DRRINFIFLD
DafO HOUSE SEWER CONNECTiNG 70 gY
P2NATE OISPOSAL SYSiEM
Si(�nOfU�C CONNECT ApOiTIONqL B:DG.OR �
OWNER-6UILDER DECLARATION WORK TO MOUSE SEWER
OVERFLOW SEEGAGE PIT,PRAINfIELD
y��reby offirm ihat I om exempt from tbe Controctor's licensa exiN.,cFssrooi,oarweu„v�nNHoie
� for the following reason(Secton 7031.5�BWS�CSS tlOd P�O- ALiER,REGAIR OR NBANpON HOUSE
Ln55iOn5 COCIC�: SEWER OF DISPOSAL SYSTEM
❑I,as owner of the property,or my employees wi7h wages as
their sole compensation,will do the work and�he structure
is nof iMended or offered for sole(Section 7044,6usiness
and Professions Code). OWNER�S Pe�mit E � CI
❑I,as owner of the property,am exdusively contrac�ing with A(JTH�RIZATION TO7AL FEE �' � /I /1 �
litensed C011ffOciOfS�O COl151fuc1 ihB project(Section�044, I HAVE AT THIS DAtE A CONiRACT WITH iHE HEREIN NAMED CONiRACiOR TO � �� Gµ4 fi
BUSifIE54 afld P�OF25510115 COd2J. CONNECT THE.4BOVE OESCRIBED E%ISTING DWELLING TO TME PVBLIC SEWER. � tl
CONSTRLICTION IEND�NG AGENLY � �_ � • � O
I he�eby affirm that there is a conshucfion lending agency SIGNEDTNIS DAYOF 19� , � ,E. e���5�i
for the performance of the work for which this permit is OWNER OR .
ISSUBCJ(SCC.3097,CIV.C.J. OWNERSAGENT C ; r�T
ADDRE55 � . ��� ��'�`�'C'
Lender's Name
Lender's Addreas -. �V'��.��!��
I certify tha�1 have read ihis appiication and stote�hat the
above information is correct.I agree to comply with all County
ordinances and State lows regulatiog Plumbing and Sewars, � �
and heraby aufhorize representotives of this County to eniar
upon the a6ov entioned pro �jy for inspaclion purposes. � �
Rc;R By:��j,�U���9� 6/16/86
$ignqture of Permittee �ate SEE REVERSE FOR ExPIANATORY LANGUAGE .
` #�'� � r • _
� � �}�� r !�' . .� �� �
` ����' ��air! �li� �► � �� ��� � '� �' �
�� �
iNavEcroie^s Notes OWNBR-BF�ICDffit D��r!r_�cR�'pjp(�
APPROVALS w„� �«seaTo.�s sw�na,.c I mernby effirm that I am e�emipt fmm the CoateacKor'c
�,���q Licmce Lew for t6e fo!lowing ntewu(S�cNo�7091.3,
Brrif�wsr asd FiaJi�aa Cad�k dwy ctey or rnwrty
w�NG� - . viLicB srqni�es o pn►nit tc cnnp'qfuY„ak�r,irRpr»tw,
)
dsr�Et6,or rs/iae mry ttn�&nr��Orbr Mt&t[vraeee.
���to �- o&e raqnms t6a a�t,Jor sKa6 pqfnit to flle a
C�voo�❑ ortvwn�p
� siga�d:tetmewt Lr ie UCeusad persia�t W tlw
. - _ p►aerisiosc qf tbs C�Nnda�i IJc+ms�Lan ICbe�tn 9
s�'r.�e svsr�cu (eon�rweeeiKq wteb Secrtnn 70�010l`lilot+los 3 oJ ebs
. . Bra:erxr mid ProJwiast Code/ar ebat be#r axomyt
��� tb�refiona a�d ebs 64firJa'e/n qusdtd t1+qr
enawi[secrK ruvtcs❑ uioJueiox oJSroeiow 7031.5 by mtya�lka�t or apnmte
sm ❑ �ssvvo�s❑ sabj�cex abe r�ppHcase re a elvt!pr�aky oJ+we+sore tbo�
, . �a�.��r�,r:saw.:
�i,��n����qmpa .am ao�.�—�
s6e.w�are u�t�una«�oc"�a�erea f�.ate.
(Ssr. 7044,Hxeis�a mrd P►ofiaiaas C,oder 1Gr Corr
� erpctar's Lfcenra L�tu do�s+wf�p fy ro�o�uws►a,(
pro[wrq�ruba 6�rJ/d!r or J�o�w tMnow,o�d ru6o doa
aucb won6 bi�teJf tLqt aa�b t�p
aev»ot lst�dsd or�Jor aok.�,;Locu�aw',eM
. bairding or�t ir mld udtbhe awe Yeor'of
� � rompltlios. tbs owwerb�ildar v�ll 6aw tbi brsda�
. . . . . of Pra+�g tLat b�ddd�ot br/fd or&sp►ow far.tba
P�����l
I aan ezempt uadec Sec. ,
B 8c P.C.for this r�nn
i
� Da�e
Uwaet
INSPEGTOR3 NOTES