HomeMy WebLinkAbout1260A � � P�TION DECLAR�tTION � � �}
I hareby offirm thar I hava a certificate of consent to self I�
� insure,or a certifimte of Workers'Compensation Insurance,or �ene<zo �S
°°°�,�';�,°° 'he��' �°°.-'e°°,�°b�., "B�`""8,8" APPLICATION FQR PERM{T
Pou�Yiai8.8 213$�Pa„YFremont Indemnity o� C
❑Cerfified�oPY is hereby furnishad. � SEWFR - SEWAGE DISPOSAL
�Ce�+�fied coPy is filed wi�h the county ildinq inspect' n COUNTY OF LOS ANGELES BUILDINIG AND SAFETY
depar�menr. �(�
Da�e�g8pplicant ,�►�C�� FOR APPLICANT TO FILI IN CONNECTION DATA
CERTIPICATE OF EXEAhPTION FROM WORKEBS' guimiN� .� p e--- � STAiION OEvrH
COMPENSATION INSURANCE A�oaess L.
- (This sec�ion need no�be completed II�IIE wOfk InY0IV2fi bY 1MC . /`WNHOIE REFERENCE uP°ER
permit is fw one hundred dollars($100)or less.) iaAut� towea
NEAREST T�'PEOFCONNECTION LENGTHfROM
I certify that in Ihe performance of Ihe work for which this caosssr. v, cuea P.L. M.L.TOP.L.
permit is issued,I shall no�employ any person in any manner • v.c.No. i
so as ta 6ecome subject to Ihe Workers'Compensation Lawz. owNEp The Anden �.*TOLlP cp.iN,v,ao. �oe rvo. [���-
'��� TRUNK PERM�T NO� RpAD GERMIi NO.
Dote Applicant noDRess
AFFI�AVIT WANER E4SEMENi RECOR�.INSiR.NO. DATE
E^`TICE TO APPLICANT: If, ofter making this Certificote of ciir �� [t.N���.--
� mption, you -should become s�bject to ihe Workers' ��� ����� 4�
Compensation provisions of ihe Labor code,you must forthwlth oesca�anoH �OT HWY.OR Si.WIDENING
comply with such pravisians or this permi7 sholl be deemed 42586
- rEVoked. BLOCK TRA STATE ENCROACHMENT �
LICENSED CONTR.4CTORS DECLARATION NO, BLDGS oERM1T NO.
I hereby affirm that I am licensed vnder provisions of Chapter saeovtot oNtoT
9 commencin with Section 7000 of Division 3 of 1he Busi- us�oF
( 9 � BUILOINGS ()IqRGES
ness ond Professions Code,and my license is in full force ond .
ef{eCf. - CONTRAROR � CONNECTION CHARGE FEE
}
License Number 'J�']L��O_LiC.CIOSS_—_G+.�'L ..— p,pDRE55 REIMBURSEMENT FEE O
-C�.J V
� Contract��R 'PTTTMRTN(7Dofe7�31/$6 aTv Riverside ,��.No. 371-5000 DISTRICTNO. GROUV n+nv veoc[sseoer V
�6-� BK PG �
❑I am ezemp�under5ec. of the l.A.Ca. ���Ns�r�o, cia5s I v �
NO. DESCRI K FEf �j
Plumbing Code and/or Sea � of ihe — Fwni
HOUSE SEWER CONNECfING 70 ' DAiE � VALIDATION �
� 8.&P.Code for ihe following reason aueucsev�a � y
$EPTIC iANK,SEEPAGE PIT OR
� GITS nN0/OR DRAINFIEIP FINAL �
Dofe HOUSE SEWER CONNECTING 7p BY
PRIVAiE CISPOSAI S�STEM
$igna�U�@ CONNECT AODITIONAI BLOG.OR .
� OWNER-BUIIDER DECLARATION woeK ro Nouse sewea
OVERfIOW SCEVAGE PIT,DRAINFIEI�
�hereby affirm ihat I am exempt from the Contractor's License exrN.,cessaoa,oevweu,N.aNHo�¢ .
for the following reason�SeCfoO 7O$1.$,�uiSfIC55 anfl PIO- AUER,REOAik OR ABANDON HOUSE �
.iOns CotJe): SEWEF OR DISPOSAI SYSTEM - �
❑I,ps owner of the properfy,or my employees wifh wpges as `''� G�'��'.
�heir sole compensotion,will do fie work and the structure � it{ � a.�1 �
is not intended or offered for sale(Settion 7044,Businass
and Professions Code). OWNER'S Permit _ y f O
❑I,as owner af�he proper�y,am exclusively contracting with A(J�"HORIZATION TOTAL FEE `� 1 F'��7,��
licensed COnffCtC/OfS f0 COnSfIUCt iMC(JIOjCCf{SEC110�7044, 1 HAVE Ai iMIS D/iE/CONiRACT WITH THE HEREIN NAME�CONiRACiOR TO , j '���2
BVSif125$pf1(J PfDIB5Sl0�5 COCIE�. � 'CONNECT iHE ABOVE�ESCRIBfp EXISiING D _WEILING i0 THE VUBLIG SEWER. ' � � r�""'U
CONSTRUCTION LEN�ING AGENCY � � � (����..��
I hereby affirm tha�there is a conshoc�ion lending agency SIGNEDTHI$� DAYpF 19_
for ihe performance of the work for which �his permit is owr�iEa�a�eNr
issued�Sec.3097,Civ.C.). -
ADDFE55
Lender's Name
Lender's Address
I certify rhat I have read this application and sto�a thai the
above information is torrecL I ogree ro comply with all County -
ordinantes and Sfate laws regula�ing Plumbing ond Sewers,
and hereby aothorize represeMatives of�his Caunty to enter � �
upon 1he abo mentioned pra ry for inspection purposes.
RCR BY;��� , y 7/31/86
Signoture of Permi�fee Date SEE REVERSE FOR El(PLANATORY IANGUAGE
� *.� r��� � q� , .�� �_ � �� '� I
�F x �' . a1�i ��_�`�� '
wae�croxs No� OWI�tER�BrAi:flBl�DE�t.A�l�
APPROYALS onh m�ee`drs srauxwa€ I 6ereby aftirai that I a�ea�mqrt fi�the Cmhactar's
�,���,� � Licmae Lsw fae the re�mn/SaeAiox 7031.3,
re mn
-. Bxslress sn�FvofimioNs C k Awy c�ity or rnu�Ey
�� � � wbicb ragriru a ptrrrit tm cowahvct.altsr,iarprona,
- dmu�olicb.or r�pq�q(ryr�t�f�4 Mla►Ai iYs knuwcw�
� r� 5 �v11ti) �
, dm nqrirev tb��!far sreG p�ernvii la,ffl�a
mse�w.x❑ oarw�n❑ ai8wad stasenrme e6qf 1»la lk�tr�d parswoss w sbo
Arou++ivac of tb�Car�LdanMn Law ICBaQirx 9
w�- ox . /corro�.ucis8+arb S�dn►70b01 aF Dlokio�3 of tb.
Bn�riw.ac ad FroJarsion Cade)o►+bat b.ts�csrmpt
.�T�_s� � �ufSeeNos7U3�bY��F�PP�'/e�'a�P�
e� �p
'Sm! Q C�asrma❑ iabpcfs tbr appHast!n a clotlpmsJgr of wot fsow iGaR
Jhre b�ndrad dotfas(iSOW�:
❑I,a.the bwnar of tlu wtll dn the wor4.and
tLe awictme L mt m�i��1e.
/Sac. 7P4h.�shc�osd eatosx Codn�i.,:ar
� � eraetar's Llceu�Imo dan wos w ma aamer of
p�roperby wbn b4iTdt or lanjiroba�ie+�,q�dtu16n dou
sweb+oarA ba��p�oatdtd tbat afreL 1Nfproe+anmp
aw»et�or q��df�a�fi�$�bo�. eba
buildind�+'�A�j k+old sutibM o�s Yap'oj
easAlatror, t6r an�a►�b�r ra�/iaos t6e brrdw
oj proutsg ebat bs dld+we Mlld or arpraw jor tb�
pruputs o1'aaL./
. . . � .. . �I Smt�7C�pt IIIII�C!'$80. �._:__�_,
8&P.C.foor this
I)+a�
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INSPECTORS NOTE3 . �-