HomeMy WebLinkAbout1263A WORKERS'COMPENSATION DECLARATIOFF � �
I here6y affirm that I have a certificote of consent to self _
inwre,ar a cenificate of Workers'Compensation Insurance,or �eraasP
acertifiedcopythe�eof($ec.3800,LabC.) CEBOB�REV.B/BI) APPLICATION FOR PERMIT
Polic�b��mPa^�''�'8mv^^=�:�sFrccma"-ri��..�7 �s
❑Certified copy is heraby furnished. � SEWER • SEWAGE DISPGISAL
}[]Cer�ified copy is filed wuh ihe count build�ng inspe 'an COUNTV OF LOS ANGELES BI�ILDING AND SAFETY
departmen�.
Date�.} ._//_Qg�/'J1ppliwn FOR APPLICANT TO Flll IN CONNECTION DATA
` E�T�IIAIt OF EXE F �M�WORKERS' etmoiNc Q t^ STATION �EPTH
COMP€NSATION INSURANCE ADDRESS
(This section need not be comple�ed if the work involved 6y the nwNHo�e aeeeaeNce UPPER
permit is for one hundred dollars(�1D0)ar less.) tocnuir iowea
NEAREST TYPEOFCONNEC710N IENGTNFROM
� mrtify thot in the performante of�he work for which �his CRO55 ST. Y. CURB o.�. M.�.To P.i.
permit is iss�ed,I sha�l not employ any person In any monner • P�NQ �
So as to become subjecf to fhe Workers'Compenmlion LawS. ownee The Anden Group CO.IMP.NO. JOB No. G f �
�^�� iRIINK FERMIT NO. � ROAD FERMIT NO.
Oate Applican� AODRESS
AFFI�AVIT WAIVER EASEMENT RECpR�.INSTR.NO. DATE
�'""'"TICE TO APPLICANT: If, after making this Certificate of pT� � re�.pb:-
mption, yoa should become subjecr to the Workers' �E�i �� /�
Campensation provisions of the labor code,you must forthwith DESCRIPiION • ���NO. ^j' HWV.025T.WI�ENING
comply with such provisions or ihis permit shall 6e deemed 4,L586
ICVOkCfI. BLOCK ACT STATEENCROACHMEM
LICENS€D CONTRACTORS DECLARATION F e�o�s. �RMir No.
I hereby affirm ihm I am licansed under provisions of Chap�er usE o��or �:. w oN�or
9(commencing with Sedion 7000)of Division 3 of the Busi- euimiNes CNARGES
ness and Professions Code,and my license Is In full force and
ef{eCt. � - � CONTRACtOR CONNECTION CHARGE FEE }
�
License Number�_��Lic.Class�_ � tt�irneuas�MeNT r�e Q
ADDRE55
COn�fadW'�.n��.�,p_D01B�� OIST2ICT NO. GROUP MAP PROCESSED BV V
��T� Riverside TE�.� 371-5000 z
BK FG
!tl 7C LV V S1ATE UC. lO �
❑I am ezempt underSec. of the L.A.Co. .uceNse no. cwss
H
Plumbing Code and/or Sec. of the No. DESCRi K RE — piNAi /J W
�r FKK15E SEWER CONNECTING TO / OAiE � /�a VqLIDATION d
8.8 P.Code for the following reason / vueuc sev.�a . 7 "�-�- � ��� � vr
SE IC TANK,SEEPAGE PIT OR �
vITS AN�/OR DRAINFIEL� FINAI
D��e HDUSE SEWER CDNNKTING TO B� � ,�.1�..
� � PRIVATE Di5PO5AL SVSTEM �'�ti"K
$ignature 07NNECf ADDITIONA�BLDG.OR ► � �
OWNER-BUILDER DECLARATION WORK TD HOUSE SEK'ER
OVERFIOW SEEGAGE%T,DRAINFIELD
I,hRre6y affirm thot 1 am exempt from the Conf�aCio�5 LiCen4@ EXiN. CESSPOOL,DRYWEIL,MANHOLE
� for Ihe following reason�SCCtOl1�O3I.S,BUiSf1E55�l1d PIO- AITER,REPAIR OR ABAN�ON HOUSE
.iOnS COdZJ' SEWER OR DISPOSAL SYSTEM
❑ I,as owner of the property,or my employees with wages as � j�� 1 ��C`�F'
their sola mmpensation,will do Ihe work and the sirudure i.;c M a � � �
is no�intended or offered for sale(Section 7044,B�siness '
and Professions Code). OWNER'S Pe�mif S Q �} ��_ .
❑ I,as owner of the proper�y,am exdusively contracting wi�h AUTHORIZATION TOTAL FEE .� t �:�( �,�:(•
licensed coniractors to consirutt the PfOjCCI�SECtiOl1 7044, I HAVE Ai THIS DATE A CONTRACT WITH THE HEFEIN NAMEO CONTRACTOR i0 v.. �. `_'��4�,r�,I'.
BUSIneSS OlICI P�OfES5i0115 COCJ¢J. CONNECT THE ABOVE OESCRIBE�E%ISiING OWELLING TO TME PUBIIC SEWER. �
CONSTRUCTION LENDING AGENCY � , D�r�J—'G�
I hereby affirm thot thera is o construdion Iending agency SIGNE�THiS - DAYOF 19_
for ihe performance of Ihe work for which this permit is owNee�n�eNi
issued(Sec.3097,Civ.C.).
ADORESS
Lender's Name -
Lender's Address � �
I certify that I have read this appliwtion and siate that the
above information is mrrect.I agree�o mmply with all County
ordinonces and 51ate laws regvlating Plumbing and Sewers,
and heraby aulhorize represenfatives of fhis Couny to enter �
upon the ak�ve-ment��d prpper�or inspection purposes.
�� ��
RCR BY•IAAe i�kf� �. Z-!�1/86
Signature of Permiltee Dote SE@ REVERSE FOR E%PLANAiORV IANGUAGE
� *� �` �'' '�"��
,
�� - _�� ' �
ixsrEcroirs Nar�s OQI+NI3R=BUIEDSR IDECLAItATIQ1Y
APPROVALS oArc na9a rees s�ov�:rw� I herebp eNirm tLet I�e:empt from tf�e Contnctor's
NEW HOUSF$EWER . � g 6 � License Law for tlse fu{iowivg mson/Sx&ow 7031.5.
Braixa� md Rw(arrosa Codr�A++y cily w oaanty
�a'�°�� w8icb,�wprires o peiadt ta carrA*et,a�r.�prorw.
,v�ioR�`�x�lto � demul�h,os raj�pur q�r ahret�Rrior M i6 auo�,a>
�se a&o f�c ibs f fOa iFi'/a LM��t ta f1Ji a
.�¢oot❑ oavwFu p s�Egnrd statnsess e�6/k�eu�d prnsmt ro tbe
� prouirin»ff�tbe Canttacfor7r Limrnt�law lCteapsrr 9
Im�wrawaeiaa w(�b SircNuw 7QQ0�9t�D&dtroa 3 of tb�
�e�r� eba+jraa ad��r afk�o mp�sA
eaaviu�r �] uinlroforoJS�tlor�s70�t.SbS�Ny�Jp�Ux�sfoe'aAus*�ie
�! ��0 s�bjrcts tbe a�ppH�vne M a c�ivU a�a7 oj�ot wwro tbaw
fiwe bratdrsd dotbrs(i300�:
�T,ai ttrc owaer a�ttu e�ql do tbe wark.aad
the stractnre ia aot inom � taz s�tte
(S�. 7D44,��wd Codt: 7b. .:ar
�i L4�ew Laar aBon��m a�.�n of
p►opar�y wEw brilds or Mtp►vaw ard mlw doei
s:ieb a+ari 6� ����bn�uu'„ tb�
w�e aat n�t�sd�d ar
brFldtwg or asprouanast�f m!d+uf�E6a ose ywr or
eor►glit(mu, slsr�r r41R+l�r tb,a�w
oj ProoiRg tlwt b�dld+wt bqJIC or 1s�roat jps ths
Pwr�6as+oJratr./
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