HomeMy WebLinkAbout1266A WORKERS'COMDENSATION DECLARATION � � -
I hmeby affirm �hat I have a certificate of consam to self ,�
insure,or a ceriificate of Workeri Compansalion Insurance,or 76nba2o
a certified co theraof saa.�,�ab�., CE 808�REV.8/B1� qpp��CATI�N FOR PERMIT
aoi;�YTrTiB.8��2i3$�mPo„�.Fremont Indemnity �a
t❑�ca�,;,;�a��Y;s,,Q,,,,Y f�,n;�,ed. SEWER • SEWAGE DISPOSAL
fJ Cer�ified copy is filed wiih the county uilding inspec'on 530/�-a� COUNTY OF LOS ANGELES BURDING AND SAFETY
deportmenl.
Date 7��i��epplicant FOR APP4ICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMP110N FROM WOHKERS'
- COMPENSATION INSURANCE nooR ss �� ,f,,' `—�°j
STATIOfJ OEPiH
(This section need not be completed if the work involved by Ihe DLSIIIOISd B`Gj.T M.4NHplE REFERENCE ��ER
permit is for one hundred dollo�s(5100)or less.) 1OCP'��rv iowek
I certify that in the parformance of�ha work for which this ossssT. Golden Springs/Carpio rvveoFcoNNecrioN �N�rHpaoM
Y. Nk6 P.l. M,L.TO P.L.
permit is issved,I sholl not employ any person in any manner p.C.Ho.
so os to become sobjact to ihe Workers'Compansation Laws, owNea � � co.innv.r�o �oe No. � LQ�,?j
��� �iRl1NKiERMIiNO. RDAO�ERMITNO.�„'
AOORE55
Da1e Appl'rcanl 3Y � Y
/F-�1 - Q� AFFIOAVIT WnIVER EASEMENt RECORD.INSTR.NO. DATE
� ICE TO APPIICANT: If, ofier making lhis Cartificate of ciTv(�'OV1T12 - -��fE�;j.�p:�-,�µ,7�9rj�f.1
'�.._mption, you should became subject to the Workers' iEGAi
Compensmion provisions of the labor code,you must forthwith oesceivrioN � No. Hwr.oa sr.wioeNir�
comply with such provisions or this permN shall be deemed
revoked. sioac T Cr STATE ENCROACHMENT
� � IICENSED CONTRACTORS�€CLARAT�ON . etocs. v�RMiT No.
SREOFLOT "� � NOWdJLOT
I he�e6y affirm thot I om licensed under provisians of Chapfer use OF
9(commencing wi�h Section 7000)of Division 3 of ihe Busi- auiiow�s R S� ��. CHARGES
ness pnd Professions Code,and my license is in full force and /�+ D • T
Bff@Cf, � �prytpqRpq R.li.L�.. Plumb ing� lnC. CONNECIION CHARGE FEE }
License Number ']7 C!n� Lif.C�o45 agno l.`d. Ve. REIMBURSEMENT FEE �
�Q'4r� ��-3-�-- ADDRESS O
ContraclB{'.R PT.iiMRTN(_Date]�31l86- . — . oisTaicTr�o. cRouP MAP 7RDCESSEDBV V
CITY TEl.NO. f BK PG O
❑I am exempt under Sec. of the L.A.Co. uceNse No. aass ��
NO. D[SCRIPTIONOFWORK FEE rj
Plombing Code and/or Sec. of the � riNAi
9 HDUSE SEWER CONNECTING TO ��'/ ,.� DATE � ��j/� VALI TION N
PUBLIC SEWER [
8.&P.Code for the followin reason SePnc inNK,seevnc�.air ou �
PIiS AND/OR pRAINFiEID FINAL � � Z�
Date FqUSE SEWEk CONNECTING TO BY
PRIVATE DISGOSAl5Y5TEM �����
$I JtIO1UfB fpNNECT AO�ITIONAI 9L�G.OR ►
OWNER-BUILOER D€CLARATION wocK ro Nouse s[wcq
1'°'^reby affirm that I am exempt from the Comracior's License MN���C SSPOOLGDRIVVJEDLpAMANHOIE
for the followin9 reason(SCCfOf1 7O3I.S,BUISIIC55 O�d Pf0- AITER,RiPAIR OF N6ANDON HOUSE
tea510t15 COC)EJ: SEWER OR�ISPOSAL SVSTEM � �
❑I,as owner of ihe property,or my employees wifh wage5 as .�.� � (�'L F.
iheir sole compensotion.will do the work and fhe slruct�re e ,� �
is not inrended or offered for sale(Section 7044,Bosiness +. " ° °
and Professions Code). OWNER�S Permit y (} p
❑I,as owner of the praperty,om exclusively contrading with A�JTHQR�ZATION TQTAL FEE �' � '�' x'��'`�'!�
licensed confrac�ors to conshucf ih6 prpject($ection 7044, I HAVE AT THIS 0.47E A CONiRACr wRH iHE HEaEIN NAME�[oNT6ACioR TO -" �-p;2
BuSif1E55 and PIofB55iOn5 COCJCJ. CONNECi THE ABOVE DESCRIBED E%ISTING OWELLING TOiME PUBLIC SEWER. ��'�� ' -'- i�^��'✓L
CONSTRUCTION LENDING AGENCY � G`,������
I hereby affirm ihat}here is a construction lending ogency SIGNEDTHIS DAYOF 19_
for the performance of �he work for which this permit is �°v`n"ER°R
OWNERS AGENT
issued(Sec.3097,Civ.C.). .
ADDRE55
Lender's Nome
Lender's Adeltess �
I cerrify tha�I have read ihis appliwtion and state that the
a6ove information is torract.I ogree fo comply wifh oll County .
ardinances ond Stofe laws regulating Plumbing and Sewers, � '
and here6y avthorize representaiives af this County to ente�
� upon ihe abo meniioned pr ariy for inspection purposes.
RCR BY;�(�hs� 1, 7/31/86
$ignafure of Permittee �ate SEE RFVERSE FOF EXPLANATORY IANGUA6F
� . �. _
�
����'�'_ ..�
� INSPECTOR'S NOTES
�WRtER Bi�II:19ffii DEQ..�R.f�TtO�fi
AP'PROVALS ow� i�rs s�r,Aw� 7 hereby aNirm rha�t am oampr�om the c.�teaecor's
r�w tqusE sEx�v . y r�r � . Licease Law for the fo rc�toa/S�ctfon 7p31.S,
. . Btuireu�atid Rofarlews'�C�� Auy dty or ma»6y
eutinl o�� u'bicb�q�rer a Pan�,it to�altK,b�roer�.
°�tn��� d�r�rb�ar rrpdr awschys�r m itr lmwwc�,
u8° r�ta�t8r�1/hs'sNs'L Rontit to f11e a
,cF�stooE O uevv�u O s�8+wd swtmue�nt 6r!t 1lmrad pirrnrane so tbs
(oemnm+�wlt8 S�os 7AQO�Uf�a�t6e
� �� Hrdr�en and Fiojwram�ss Cadrl or ebsc bs ii aa�pt
sirocu� 'a�3ect�an 70$�b,K �1leu�=oeaprn�i'Yi
CT c�Sroo�s p au8jrctr ibs�p(kawt As o eMit
JEw b�+Adewd doAars R100�.: ���ot fuare tbmi
p I,es ths oavaee�the wIll da t6e 9r' wd
t6e aa�act�¢s ia nat inte�a��ot�ed fi�c wle,
(S«. 7lM4.Brt6�ax od Pfrojialo�c Co4�r TJaa Cor
:ronur�Lfnsrs Law daa wat app�m me a�r ef
pr»p+rty+vbo brildr or hieprnv�s tb�now.asd rabo doa
srcb wm°�i 6i�►�P+ao�nd rbaf dteb�rouan�b
are wot ist�p{ar q�an�Jor min{�f,hm�va,eb
bu:ldin�g or�avrn�o is sold+o/ttdn mN ys4r oJ
ce+o+Phrfiois tbe ow�ar�mJdd�r rdll 1eQw tbs bYndrs
oj provie�g t(wt bo d!d fws b�d or lqrP+ons lor e1H
A�f�•ol�1
I am e=empt a�udet Se�. ,
B&P.G for t6is�
Date
Om.��er
IFRPECrOR'S NOTEffi ^