HomeMy WebLinkAbout1252A __ . � �___�__�_ _ ._. _ _ ._ �_ ._
` , � - � " -
- ERS'COMPENSATION DECIARATION . � �
I hereby� rin ihat I have a certifitate of mnsenl lo self �
insure,or a carfifiwte of Workers'Compensation Insurance,or �aneazo _
Poi�Y`I��g°�'���°�`�mpp e'�°"re�tont Indemnity ��°BiRE�B a, APPUCATION FQR PERMIT
�Certified copy is hereby f�rnished. SEWER • SEWAGE DISPOSAL
Ce���fied copy is filed with rhe cou�ty ild��g inspecti � 530 A COUNTY OP lOS ANGELES BUILOING AND SAFETY
deportmenr.
Do�e_^�:/�1 l R 6ppl icom�_ FOR APPUGANT TO FI Ll IN CONNECTIDN DATA
CERTIFICAiE OF EXEMPTION FROM WORKERS' eunoiNe /� STATION OEPTH
COMPENSATION INSURANCE noosess �Q �.f7} �
(This section need not be complated if fhe work involved by the �p�q��YY DlamOnd BaY• Nv1NHOLE REFERENCE � . OWER
permit is for one hundred dollars($100)or less.) Nenaest Golden �J T1T1 5��.'1Y 10 N�°F�°NNERioN �NctH Faorn � �
I certify thot in ihe performance of ihe work for which ihis [aossst. P g P Y. CURB P.L. M.LTOP.I.
permi�is issued,I sholl no�employ ony person in any manner
so as to bemme su6ject�o the Worked Compensatian LawS. pWNER CO.IMF.NO. lOB NO. IQ �(�p
��� TRl1NK VERMIT NO. ROH�PERMIT NO.
Dole Applicont A�DRESS
���TICE TO APPIICANT: If, afrer mokin9 fh15 Certificare Of CIiYCovina �:r'""�-Na; 67-9541 . ^FF�o^v�T WAIVER EASEMENi RECORO.INSTR.NO. DATE
.�mption,, you should become subject to �he Workers' �E�A� . �
Compensation provisions ot ihe labor code,you most forihwi�h o[sceivnoN � ��S � HWY.OR$T.WIpENING
comply with such provisions or this permit shall be deemed
revoked. eiocK iRAC STAiEENCROACHAIENT
NO.OF BlOGS, PERMIT NO.
UCENSED CONTRACTORS DECLARATIDN 5¢e OF iOT Now ON ioi
I hereby affirm tha�I am licensed under provisions of Chapter use a
9(commencing with Sedion 7000)of Division 3 of the Busi- auimwcs a�aa�es
ness and Professions Code,and my license is in full force and
effecr. cavrancToa R.C.R. P lumb ing� IIIC. coNNecnoN cNaace Fee �.
License Number �����_lic.Class �r�6 gno la V0. �
AO�RE55 REIMOURSEMENT FEE
COnIfOCf�� PT.'[TMRTNGDate,ZJ..31lf3h� ersi e. � DISTRI�iNO. GROUP MAP PROCESSE�BV V
❑TY iEL.NO. BK PG �
❑1 pm ezempt under Sea � of ihe L.A.Co. iiceNSe NO. c n55 /a �
H
No. DESCRI I O RK FEE {.7
Plumbing Code and/or Sec. of tha HousE sewea coNNecTiN�To �rf -._ onr�� �j �,1/� VALIDATION L
B.8 P.Code for the followinq reason Puauc sewea y
SEPTIC TqNK,SEE?AGE GIT OR �
� Vi1S ANP/OR pRAINFIEID FINAL n
DOte HOUSE SEWER CONNECiING TO B� ��J/� ��
pRivATE OISPOSAI SYSTEM ✓��/��Y�
$i(JnptulE CONNECT AD�ITIONAL 9lDG.OR ,
OWNER-BUILDER�ECLARATION wOaK io HouSe sewea
�, re6y pffirm�hat I om exempt{rom ihe CoMraclor's Litense �XTNf��CE55EPOOlGDRVVJElpMAN OLE
�for the following reason(Sedon 70.31.5,Buisness and Pro- a�rex,aernia oa nenNooN No�se
oaolO�S COdC�: $EWEF OR�ISPOSAL SVStEM :�_1 C��G iq
❑I,as owner of the property,or my employees wilh wages as � e 1 �
their sole compensation,will do ihe work and�he structu�e '' - °
is not imended or offered for sale(SeUion 7044,B�siness . r r
ond Professions Code). OWNER'S Permit 5 �0 Q J " n G l.,;;)
❑I,as owner of the properry,am exclusively contracring with AUTHORlZATION TOTAL FEE � r- 7
licensed contractors ro construc�the ro'ec� Section�044, �-f � �' r'`��'�
P I I 1 HAVE Ai THIS pAiE A CONTRACT WITH THE HEREIN NAME�CONTRACTOR TO
BU51l1055 O�d PfOf¢SSi0�5 COfJB�. CONNECT THE A00VE OESCkIBEO E%!STING pWELLING TO iHE VU6ll�SEWER. n.V r`�,L.•6
t' t,
CONSTRUCTION IENDING AGENCY � �
I hereby offirm fhoi there is o constr�ciipn lending agency SIGNFD7H15 DAYOF I9_
tor the performonce of ihe work for which this permit is owNex ort �
OwNERS AGENT
issued(Sec.3097,Civ.C.). �
A�DRE%
Lender's Name
Lender's Address
I certiiy thot � have read this opplimtion ond stote thot Ihe
above information is correct.I agree ro comply wifh all County �
ordinonces and Slote laws reguloting Plumbing ond Sewers, � �
and heraby authorize represantatives of this County�o entar
upon 1he abo -mentioned rope for inspection purposes. �
RCR BY; p��,r �_, 7/31/86
Signature o�ermittee� � Date SFE REVERSE FOR EXPIANATONY IANGUAGE
r��
,
_.�, _ _
iasrErraa�s Nor�s OWNI3R.BL�31�.HBR DE�I:A�BATI�N
APPROVALS na� nae�aen•s sKra�wac I taeeebq aHixm tLat I emeumpt fro�the Gonttmm�s
r�w Housc sew[a License Lnv fax tlte folbvving eiaon/S�x 70�1.5.
� Hrrinosr a�d R�tiowc Codeh A�ry city or wnwey
'��� � mbw:b srq�ires a pmwfe to caw+#+rcf.alfir,&npronR
r �► �t dosolfsb.or r�p�ir aMac�nk,lKlo+to Jq iasmicv.
an�`� a&o req,� tbr�e for sRcb�(Mrn�t Ov j1JB a
�Seooi� m+nua�Ll .tige�ad statmeae Irs 4 Ike�urd pwsras=aa tbe
P+ovisians�t6s Cm�pactnr's LkwHe Lav(Chaytt�r 9
(coroxru�i�udtb S�cNw 7000}oJ I)MB(as 3 of tlw
A�i� B���=Nmf�oas�m�eGu bs ir e�p�
t allgrd stnnpNo�.A�yr
�� E2 �❑ srbj�cer eL�T�a���jne�t
fiue bx�dnwd dollwa(SSQD�:
�I;as t5e oumer di tkep wNdott��-z aad
thc etroetore ts nat d�e�or affiaed Loe sde:
(Soc. 7044�Brd�eB��u�t P�nf��lo�s Codn 17tie Cos.
tructur's Lic�Law dwt�mt m ot o�uurr of
proper6y wbo balt8t or fip(�naos �d wbo doar
srch+r+�kN�xd/�abd r��Lapiooansnm
mr aut:wtasdd or Jor mk.�`,bwu�va,tlia
6u:ldt�,q or dspran�c ts aol3 x�te ase yaor uf
aw��phdos, ths awn�n.L+slldPw�ulA bsao t8s baadsn
. oj proviwg tbat b dfd�brlld or iwpeoor jos t8a
�of+�l
I em�gt muder S�. ,
B&P.C.faz tLis reaam
Date
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