HomeMy WebLinkAbout1493A (8)`_ -
WORKERS COMPENSATION DECLARATION
_
I hereby affirm }lint i have a cert ftoate of consent to
-se1`f .,
` Insure or a certificate of Workers Compens'atlon Insurance, tri-
:; 75 cerllfte thereof (Sec 38b0 Lab C )" _
Policy Nd mpany- �'' .E'7T1.fi _ _
CE eo6 !Rev e,81 1 �A�
®: 01 1 i��IYi�
1
fit m
Cgrhf d s eby furn'Ished
�EYY� YY
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'. Carhfied copy is filed With the county building inspection
COUNTY OF LO$ ANGLES
IMED.IW AND $A-FETY-
=t�� ivd
�DotegXRIIApplicant
-.
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' rc p � f
FOR TO FILL IN
CO- NNCTIO-.. ..N DATA
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C MPENSA%MP`IKI-l
�,, 1hiSU�f dY
(This compiete8
�A.,PPLICANT
DEPTHIIDING
sranoN
,.
section neeo nq be f the war involved by the
•-+' 'perinif isfar one hundred dollars ($100) of less)
LOCALITY -
- _ - 'UPPER
MANHOLE REF """ :
ERiNCE _ LowErt
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1 cerfif that in the performance of work for which this
p
NEAREST - - ": "'
Wass sr
TYPE OF CONNECTION- LENGTH'FRb�A" -
-
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pe n f is slued f not employ any, person m any manner
v cuRB PL ML iO P,t
50 as t0 become sub�eCf 10 the Workers �OnlpenSailOD Laws
subjhallect
p'r�7T�
OWNER Il.3,YY% ..
PC rvo /
C4 IMP NO, JOB NO:b
i>}k, af'E6"
V
a
Date A�pplicani
ADDRESS' " -.' .. ..
NK PERMIT NO . ROAD PERMIT NO. -
% ;. G. -per r� d:
atter making "fftls l-eYtirlcote Qi��'
_
CITY ' TECIAC
FFIDAVIT WAIVER EASEMENT RECORD INSTR' Nb: DATEmesubject
'to the Workes'�'��".f•.--
LEGAL
n ly wth such routsONS OrOhsr perm)shambe fddeemedith
Y p P eemed
DESCRIPTION-LOY NOY.
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OR ST.: WIDENINGP
:TRACT 7TE
ENCROACHMENT
BTOGSMIT
NO .o.ok,_..,:�.US
thereby affirm That I:am licensed under prov sions of Chapter
EOE LOT NOW ONLOT
ng with"Section 7d6Zi) of Division 3 of the Busl
ng•.commenc
BVILoGs
s-
nes§ §,TdP ofessons Coda and my license 4s n full forte and'�� -%�:�T'm
CHARGES
I nye i�llm6erL1[ Class f`'��
CONTRACTOR
NNECTION CHARGE FEEpe
$17
ADDRESS 8G''.
MB URSEMENT FEE-Qa�ema
Do}e
'� : ta9r s
CITw �,'t `d', 0 .. .TFL N
5TRICT�NO.
GROUP
MAP"
PROCESSED EY
VSorrtracto
-.h .s
the L'A Co -
srATE "' '- - -Lie
DG'
K -temptundeiSecf
ZO
,
ng Code unci/or Sec the
LICENSE N0. S QASS0
NO- OESCRIPTION OE WORK , .�..
of
F ''
fortheforlowing eason-
HOUSE5EWER CONNECTING TOr
PusacsEwER"
nL_i
TE
9,�s�PRV
W
VALIDATIONode - o'In
,-
T� 'L S <
.'' SEPTIC ANK,SEEPAGEPYOR
.PITS ANDIOR; DRAINFIELIi
AL -
--
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ate:
HOUSE SEWER CONNECTING To'y�
TE DISPOSAL SYST""signature
-' -
z•b S l 'f O1'VN�ER $rJl�?ER [St=C�il'£A"Y,
" W� �" . _ , �. �•5
"ffrm
-CONNECT ADDITIONAL OLDG OR
'. WORN TO HOUSE SEWEk
.
,a y},, �. i^,:
I hereby that I'
" y o am exempt f;am the 40ntrtlftOr s-LICen9e
OVERF[OW SEEPAGE PIT GRAINFIELD
'.E% N., CE SSPOOL,-DRKMELL NCANHOLE
.
L law fpr the follow ng reason ($Bcfon 7037 5 BulSnesS and Pro
.. .,.,�_..w.
ALTER REPAIR OR RBANDON HDTJSE
".
4.�.J
HSIOnS COdeJ
SEWER oR bISPOSAl S`/JTEM
I - -
I, as owner of the property, or my employees wMh wngas qs
-, a.�obtG
their sole 11
compensation, wil I, do the work and the structure
- - - -
-
IS not ntended dF offered for,sale (Section' /044, Business
-27,50
did Profess ons Code).
OWNER'S Permit g 10 50 -
❑ I os owner of theprope ty, am exclusively contracting with
AUTHORIZATION TOTAL F�,f
b -
licensed COntraCTO�v'rs to COnstN 1 the project (Section.'764'4;
"` B1 91neS9 and PraTe55 Ona Cpde)
I HAVE.: AT THIS DATE'A CONTRACT 'WITH`THE HEREIN NAMED EoNTRACTOR TO
CONNECT. THE ABOVE VESCRIBFD EXISTING DWeLLMG;TO THF, PLl ;$_EWER
- a
2 9r � E� O
rt✓ , -' �§, CONSTR`l)C71�O�LE�IY�IN`G"i1CiEKYC`P ,'"''- �"i
_1q
- °��� (]�.-
-
I ne eby off rm that-"iniereIs a -construction len ng agency
SIGNED TH is DA OF Sl Iq
OWNER OR`
f for }he performarcCe of the work for which this, permd is
.-
OWNERS AGFr���'ON'I-�f'��
AA r >Y;;I- :r i
--
fs Xw`. sail-^ i., F?&f1r. k,.ai,.S i.w 1-'+3Ie A'':*.' -1,.. zt�4.."ina�' ,+53, '::tea ^4
I hoveread this dpplicahon and state that the .. .
Ef
rect., I, agree ws regulatinepresentativeed property K ,..:.. -e= e
`
WNER, DER MaARATIO
'J
Ro
APPROVALS
DATE
I hereby affirsa that I am erempt from the Contrartoes
NEW H OU ER
NEW HOUSE SEWER
Any ci
CONNECT ADDITIONAL
which requires &-permit to cane'trytt, alter, improve,
OR _RK
BUILDING OR WORK
de Qib
AND�OBEFIT CTA _I FIE D'
R IEL
OR
or "qsug the' appiicant, Jbr such permit to flIe a
EDDRAIN
CESSPOOL 0
7
IT ERC
R 11, SEWER
(commencing with Section 700 0) of Division 3 of tile
JREPA'
""Bus—Aiss C04) or that be is exempt
ISCONNECT PLUG AND
ABANDON HOUSE SEWER
ia� and the b"Jar the alleged exemption. Any
BACKFIU.,SEPrIC TANKS 0
2,
Section 7031.3 byasty4plimIstforapermit
rove hundred dollars (S�00)..
L as the owner of the property wiD do the work, and
the strbicitti -e is not intended or offered for sale.
eset. 7644, Business and PWeisiow Code.
license
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