HomeMy WebLinkAbout1242A WORICERS'COMPfNSATtON DEfLRRATl0t4 �
I hereby affirm thot I hove a ceriificate of<onsent �o self �
insure,or a certificate of Workeri Compenwtion Insuronce,a �aneefo
aceYf��,��,����cP.n�uremo�ht Indemnity ��8(REV.B/81) qpp��CATION FQR PERMIT
Polic
�ce.��f�ad�oPY is hereby furnishad. SEWER - SEWAGE DISPOSAL
de�rt��d�p,y�filed w��RCR B fY b 'Iding inspection � COUNTY OF LOS ANGELES BUILDING AND SAFETY
25 �'
Date Applitant y� �h 1G_�['� . FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FRpM WORKERS' aui�oiNc L � OS Z STnnoN � oemH
COMPENSATION INSURANCE nooaess
(This section need noi 6e completed if the work involved 6y the .D11II10ril� .B2Y �"^NHoiE REFERENCE . u°PER
permit is for one hundred dollars($100)ar less.) LOU'��'Y iow�R
I cerlify thal in the performance of�he work for which Ihis �Rp�AT TYPEOFCDNNECiION �N�iHFeon�
� Y. CIIRB P.L M.L.TO P.l.
permit is issued,I shall not employ any person in any manner p.c rvo.
so as to 6emme subject ro the Workers'Compensation LOwS. pWNER South Country �Corp, ca.iMa.No. �oa No. %�� . �
��� ' • OX TRVNKPERMITNO. ROADPERMRNp.
Qpfe AP�JIiCOf11 ADDRESS � �
� TICE TO APPLICANT: tf, ofter making fhis CBf1if1[OfE O{ CIiY �.� �rE��.. � � AFFiDAVIT WAIVER EASEMENT RKORD.INSTR.NO, DAiE
emp�ion, you should become suble« fo the WOfkef3� LEGAL
Compensation provisions of rhe Labor code,you musi forihwith oe5cuiarioN �or O. HWV.025T.WIDENING
comply wilh s�ch provisions or this permit sholl be deemed f.,L58
fEVOk¢C. - BLOCK TRA 'f STATEENCROACHMENT
Of BL6G5. PERMIT NO,
LICENSEDCONTRACTORSDECLARATION sizeor�or ""�-�` woNior
I hereby affirm rhat�am licensed under provisions of Chopter use oF e51 EII 18
9(tommancing with Section 7000)of Division 3 of}he Busi- BURoiNGS [Hae�eS
ness and Professions��Code,and my license is in full foLrce and
e"ef' 336428 C��v CONTRACTOR CONNECTIONCHARGEFEE
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License N����i[.C�S�}�,��� qpDRE55 1� REIM6VRSEMENT FEE O
Controctor Date , � CITV Riversiiie � 7E�.No714-371-�5000 �ISTRICTNO. GROUP MAP, PROCESSEOBY V
f BK PG Z
❑ I am exempt under Sec. of fhe L.A.Ca. iicevse No. 6 clqss C'�`jb /� �!- -
PlumbingCodeand/or5ec, ofihe "�� DESCRIP710NOFVJORK ree FiNA� `j
HOUSf SEWER CONNECTING TO DAiE VALIDA ION W
B.&P.Code for the following reason PUBUC SE'JJER 7 �- /�2 �f ��' y
SEPTIC TANK,SEEGAGE ViT OR FINAL �� Z
PIT$AND/OR DRRINFIELp
. ���e HOUSE SEWER CONNECTING i0 BY
PRIVAiE DISGOSA�SVSTEM
$19nOtUre CONNECT ADDITIONAI BIDG.OR , �
OWNER-BUILDER DECLARATION woaK ro Nouse sewea
f"�reby affirm Ihat I am exemp�from the ControUor's License �TNf�OC SSPOOLGORYWELRAMANHIXE
.for ihe following reason(SCCfon JO31.$,BUISO855 Ond Pf0- ALTER,REPAIR OR AeAN00N HOUSE
te55iOf15 COCIB?: SEWER OR�ISPOSAL SVSTEM �
❑i,as owner of�he property,or my employees with wages as � �
their sole compensation,will do the work qnd the structure .
is not infended or offered for sale(Saction 7044,8usiness
and Professions Code). � �WNER'S PE�mif y /(j <"Q
❑I,as owner of the property,am exclusively contracting wi�h AUTHORIZATION TOTAL FEE '('.j ;r'� �Q �.A
licensed confroctors to conshutt ihe project(Seciion 7p44, i NAVE AT THIS�ATE A CONTNAR WIiH THE HEREIN N4MED CONTRACiOR TO
Bu5ine55 and ProTE55ion5 COdBJ. CONNER THE A60VE OESCRIBE�EXISTING�WELUNG TO THF PUBUC SEWER. 'f'.'�, � a�p � O
CONSTRUCTION LENDING AGENCY � r
I hereby affirm that there is a construclion (ending agenry SIGNEDTHIS OAYOF 19_. � r�,o��'],�,f�
for the performance of the work for which this permit is �'�ROR .
issued(Sec.3097,Civ.C.j. owrveas n�eNr �� ,,,�V`.r
Lender'sName nooaess � � -� '
Uz'c6 --86
Lender's Address -� �
I certify that I hove read ihis application ond state that fhe
above information is correct I ogree ta comply wi�h oll County �
ordinances and State laws ragulating Plum6ing ond SewerS, �
and hereby authorize represen�atives of this County to enter �
�gpp�ylh6,Oboyg-mentioned pro erty for inspRcp9n�p�rpqces.
�cl,Lt Dy /I O/l p 0 0
t
Signafure of Permittee �Date SEE REVERSE FOR EXPIAN�TORY LANGl1AGE
uaretroms�om OVfrNE�HF)II:13SR�DBCL�iYi�ITION
APRRCVALS oA� "mswcroxs s`wanw� I 6aeby af6rm tLat I am ex�pt fmm tlfe Cmueetm's
��y��� ¢,� Licenee Laa for the fdlowrjag tmon(S�ctfor 70;1.3.
Bw;nase�d Ayfsnevwr CodsJ�Any dy or mrxsy
e°mdi oiaoa�woe� wbicb+�qauQa a parndi so co�+f►rsR a1Ar,hArpro�q
de�na�dte4 m'.'eA�air asy+t+rcOrew prtor to itr luamies.
�o'�"drna�e�io°�(� also ro4�iras tbe appl(qm�t for nreb�nwt to fils o
a�wa O oa�wcu❑ si8*rd rwmnnu tE�x bs ti 11�sed pwraoa�t ee ebs
proe�i�rioss of tbe Cow6retar4 Iicwrra Lam lCLaPM 9
�uR��a�w�� /canree�u.rs8 wit6 Sectloe 7000}of Wtkios 3�R6a
'�t�dt�s�at B���� G�or l6pt be is axeinpt
!w' dLdrd ninsptiaw.dwy
'gEv C� �s❑ � sabjsc��i oppliaxw tre�i�pe�aW��
. f:�.a�..i�tr�/sso0�.�
❑I,sa rhe owner aR the wiU dot6e w{—9nd
Jte suacto�e ie eat i ox�tor p�.
IS+c. 7044,Busi�o.s��esiiau Cadu Ths Coa-
. . traNcr'e L4.wi Leta dou Mot�pby w ur ouarer of
- proparty wbo bpilds a�ir�piooas Wrsow,ard mbo doa
srec8 work �w�f prmild�d tlwi aiYCL Nnp►voawieuts
are wot Mu�Q�or�ard Jor yok.{/,bo�o�ews elx
. . .. .. huifding ar�rxa�t!s sold+atthlu o�s ysor oj
c+orKplrtiar, sbe owrewbniidsr wiA'Love tlw br�drn
oJ p,rouiqg tliot be dtd wot balfd or bxp»w jor tb�
. . prryaia ojrd�./
I am ezempt aadee Sec. ,
' B&P.C.for tLis reasan
Date
Otauec
1lMPEROR'S NOTES . .