HomeMy WebLinkAbout1265A WORKERS'COMPENSATION DECIARATION � �
I hereby affirm that I have a certificate of consent to self
insure,or a tartificate of Workers'Compensation Insurance,ar �6A64E0
o certified cop ihereof 5e�.�3�,�ob�., � �E�e�RE�.B,e�, APPLICATIpN FOR PERMIT
aau�YL�86�213$�mpan�'remont Indemnity c�,
�-Certified copy is heraby furnished. � SEWER - SEWAGE DISPOSAL
Certified copy�s filed with the counry uilding inspecti �, 530/:3 Q� COUNTY Of LOS ANGELES BUILDING AND SAFETY
deparimenl.
Dare 7�'2l���Ae,pplicont FOR APPLICANT TO F1LL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' auiioiNc n ,-- srnnoN oerrH
COMP€NSRTION INSURANCE aooaess CX
(This seclion need not be comple�ed if fhe wark involved by ihe � bWNHOIE REFERENCE UPFER
permil is for one hondred dollars($100)or less.) �oUutv Diamond�+.Bar i v.�a
NEAREST Golden J rZn s/Car 10 TY7E4FCONNECTION �[IVGiHFROM
I certify Iha1 In the performance of the work far which ihis CkO555i. P g P v. Cues P.L M.LTOG.L.
permi�is issued,I shall not employ any persan in any manner a,c No. p
so as ro become subject ro the Wwkers'Compensation LpWS. OWNER - CO.IMP.NO. JOB NO. ���'y
��� � • TRUNK PERIuIIT hq ROAD PERMIT NO.
Date AP(.11iCant ADDRE55
�p� AFfIDAY1T WAIVER EASEMENT RECORD.INSTR.NO. DATE
/"'TICE TO APPLICANT: If, after making this Certificate of ��T�('iOV1T12. "���te�.wd^r{�w.�'"9541
� .npiion, you should become subject to 1he Workars' ��Ai Z
C6mpensarion provisions of rhe Labor code,you must forthwiih oe5cuivrroN �� NO. NWY.OR$T.WI�ENING
comply wilh such provisions or Ihis permit shall be deemad
/CVoItCd. � BLOCK T Ci STATEENCROACHMENT
� LICENSED CONTRACTORS DECLARATION .OF etoGS, �RMii NO.
SRE OF LOT NOW ON LOT
I hereby offirm ihat I am licensed onder provisions of Chapter use oF
9�commencing with Section 7000J of Division 3 of Iha Busi- eullAiNGS R �. CNqRGES
ness and Professions Code,and my licanse is in f�ll force and
effect. caNruntTOR R•C.R. P lumb ing, IriC. coNNecrioN cHnace r� �
License Number ��;�_Lic.Closs �_� nooaEss agno 11 V2. qeiv,guaSeMeNT Fee O
ConifadB�R PT.iTMRTN(:Date7/'�1/iph . ' oisTaictNo, �Roua MAP PROCESSEDBY V
Y CITY 7EL.N0. gK PG Z
❑I am exempt under Sec. of the LA.Co. iicinise No. cLass �2� �
Plumbing Code and/or Sec. of iha �� DESCRIP710N OF VJORK FEE PwaL VALIDA �N 0.
HOUSE SEY�ER CONNECTING TO DATE
8.&�P.Code for ihe following reason PUBUC SEWER �� .� S� ur
SEPTIC TANK,SEEPAGF PIT pR Z
VITS AND/OR DRpINFIELD FINA1 �
DO1e HOUSE SEWER CONNECTING TO BY ����L��../�
PRIVAiE OISPOSAL SVSTEM
- Signature CONNECT ADDITIONAL BIDG.OR �
� OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERfLOW SEEPAGE PIT,DRAINFIElO
oh�reby affirm ihat I am exempf from Ihe Confrattor's License exmi.,ce55POa,oarweu,nno.NHO�E
, Sor the following reason(SECiOfI 7O3I.S,BUISI1C55 Oftd PIO- ALiER,REPAIR pR ABANOON HOUSE
.�Of15 COC�E�: SEWER OR PISPOSPI SYSTFM � '� ,����
❑I,as owner of�he property,or my employees witb wages as �
their sole compensation,will do the work and the structure �..` 0 ``�� {�
is not intended or offered for sale(Seciion 7044,Business . C�
and Professians Code). OWNER'S Petmit E � � I n ��i���
❑I,as owner of the property,am ezclusively contracting with AUTHORiZATiON TOTAL FEE „ � c- s
�IGBnSBt�contractors to consiruct the project(Section��44� I HFVE AT THIS DATE A CONiRAC�WITH THE HEREiN NAMED CONTPACTOR TO . �� ` J�����L
Bu5if1E55 OfIfJ PfOfB55iOf15 COC�2. CONNECT THE ABOVE DESCRIBE�E%ISTING DWEILING TO iHE PUOLIC SEWER.
CONSTRUCTION IENDING AGENCV �����r�Y��
I hereby affirm that ihere is a construction lending agency SIGNEDTHIS �AYOF l9_ ,
for Ihe performance of ihe work for which this parmit is owNEk�nGEni �
issoed(Sec.3097,Civ.C.). �-
.aooaess
Lender's Name
Lender's Addrasa
I tertify ihai I hava read this applimtion and state ihat 1ha
above information is correct.I ogree to comply with oll County - �
ordinances ond State laws regulating Plumbing and Sewers, � -
and hereby outhorize representatives of this County to enter
�pon fhe abo manfionad pro ty for inspection purposas.�
RCR BY; �Q�,�, 7/31/86
� Signature�Permiltee Date SEE RFVFRSE FOR E%PIANATORY LANGUAGE
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