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HomeMy WebLinkAbout1237A WORKERS'COMPENSATION DECLARATION '� q I hera6y affirm that I hove a certificate of consent to self � , ��� � �I insure,or a certifimte of Wo�kers'Gompeowtion Insurance,o� JOA°^20 • � ��� � 11 acenif�������f`�o�t �ndemnity . �;°�`REV�e"8j� - � � APPLICATION FOR PERMIT Pou�,. �Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL - Certified c p is f�led wi�h the couNy b Id+ng inspecro }30� A COUNTY OF LOS ANGELES BUILDING AND SAFETY d������b RCR sy: Dare Appltcont FOR APPUCANT TO PILL IN i CONNECTION DATA � � CERTIFICATE OF EXEMPf10N FROM WORKERS' y��ia� . � � � � COMPENSATION INSURANCE ' � - now�ss - srnna+ � o[vrH - .(Th�s sectio�need no�be completed�f tMe work invol�ed by ihe ipUaiTr DZH�OIId BHY MANHpIE REffRENCE � ��R pe�mit is for one hundred dollan(SI00)or Isa.) . I certify�thot In the performance of�he work for which ihis ��a�ouST - , rra[ovcor+r�Criora _ _ �r.�THppp,y,� . ' permit is iasved,�shail no�employ any pmson in aay manner Y� �CURB P.l. M.L TOP.I. -'so aa lo become subject lo the Workeri Compenao�ion LtlwS. OWNER ' CO.IMP.NO. J08 NO.. C�I�'� ��� TRUNK PERMIT NO. ROAD PERMIT NO. '' Dare Appliwnl � noowc55 X � � /''�1 TICE TO APPIICANT: If,� aher making �h18 Cer�'rficate Of� - ��Ty Covina 818-967-9541 pFfIDAVIi WAI�ER EASEA�NT RKORD.INSTR.Np. DATE f �mp�ion, yoa should become subjec� to the Workers' i�ai . � � � �ompeowtion provisions of Ihe Labor code,yo�must fo��hwith p($�RIMIdJ '-lOT ' HWY.OR ST.WIDENING comply with such provisione or this permit shall be deemed ' fBVDI[Qd. � . BIOCN TR SiATEENCROACHMFNi LICENSED CONTRACTORS DECLARATION p� PERMIT NO. I heroby nffirm fhat I am licensed under provisions oi Chopter-- _ 5¢EOc lor Ora�Ot ' � �, 9(commencing with Saction 7000)of Division 3 of the Busi- su ioiNcs tH��s neas and Profeasions Code,ond my licenae is in/f�ull foLrce and—� . . . �ffeC1. 336428 y�3u COMRA[iDR CONNERIpN�HARGEFEE y license N'RLbR��a CCp�s}�T�� � C a AppqEr� REIMBURSEMENT FEE Q COl11lO[10! '�O�p . OISTNI�f Np. GROUF AMV iRO�E55E�BY V ' � CItY . . t.NO. �BK PG Z ❑1 am exempt under5ec, � of the L.A.Co. iiceoist No. � cuss � _ / � Plumbing Code and�or Sec. of the N�� �ESCRiPTIqJOi WORK FEE � F�Hpi� V . 110VSE SfWER CONNfCTING TO . /� L OAiE �� e VALI ATION n. - B.8 P.Code for the following roason PUBUC SFWFR . � '�f SFPTIC TANK.SEEVAGE%7 OR . N � �Ii5AN0/OMpRA1Nf1ElD fINAI ? ... Dale � IquSE Sf WER CONNKTiNG t0 BY PRIVAtE DI l Y TEM ' � Signature � � corJwrcr aoomonui az�c.at , � � - ► . . --� - � -- OWNER•BUILDER DKLARATION wocK To�wux s�vrta � _ OVERiLOW SEEMAGE Yli,DRAINfIEID � I hereby offirm that I am exempt from 1he�CoMracror's Licanse [xTH,cessaoa.oarweu,nuNHott � � � . � ._.... . . . . . ��for ihe followin9 reoson(Secton 7031.5,Buisness and Pro- xha,aen��u ort�.a�NooN ravse � • ; :ionsCode): . seweaoaDisvoS�t5r5rE�n , _ ❑I,os owner of the proparfy,or my employees wiih waqes os � �� 2 a 7� � their sole compenwrion,will do the work ond the strucrure ��� � � ' � . . is not intended or offa�ed for sale(Section 7044,Business a�d Professions Code). OWNER'S Permit S , . �'° • °• � � ❑I,as owne�of the property,am e:clusively controcting with AUTHORIZATION TOTAL FEE I o e 2'],5� licensed tontractors to conslruct the PlO�BCi'S9CIi0f1�04�, �Hqy(q7 TNIS�ATE A�ON7RA�(WITH IHE HFiE1N NAMFD CONfRAC70R TO , ' � 6u5ina55 and WofesslOns COde�. CONNECi THE ABOVE DEiCR1BED E%ISTING DVlEIIING TO TNE PU&IC SEWER. � �ry e 2 7,S C� CONSTRUCTION LENDING AGENCY - � � - � � � � � - �� �- � I hxab o(fiim fhot the�e is a coostruction lendin o anc SIGNE�THIS DAYOF 19_ Y 9 9 Y o,�,�R� ` DS25-86 (or the performance of the work for which �his permit is owneasnc.�r+r � -� - � � � � � � - - � � � issoed(Sec.3097,Civ.C.). , � - . . AUDRE55 , , . . lender's Nome Lender's Address � � - � " � � �� � �- " - - I certify thm� have read this application aad staro tho�fhe - � � obove information is corrocl.I agrae to mmply with alI Couny � - � � �. � � ' - -� ', � . -�-� ����---� � � -�� wdinoncas and Slate laws ragula�ing Plumbing ond Sewera, ' ' � � . , �, ond hereby ao onze ropresenratives of this CouNy to anter - . � - � . � � . �� - �- � � �yppq fhapbov menlioned propf�rty for inaRet{i9rypyrpqses. . ��, 1SVA lSy /j I fJ O/1��00 , �'411�_ll�'7�' . . .. . . . . . . . Signature of Pe�milfee Date SEE RfVERSF FOR F%PIANATORY UNGUAGE � • ursrEcroR�s Nores OWNER-BUII:DER I]ECLARATION _... . _. APPROVALS OATE ivsvccroa•s s�cranTuae, - I hereby aHirm that I am eumpt from the Contractoc's �,��R . . t .,. . License Law for the followiag rawn(SacNow 7031.5. ' .. . . .. . Bweixou uwr�Prgfexioru Cod.k AMy�ciry or co«Mey ao�ecr�ownor+�t r w6icb riqirir�s n pern.ir ta co�strtiet,alhr�improve. � euaon+c ae waeK. . - � . ,_. . . . • ��-�.. '..dwno!&6,or r�Qair awy ahrNw�,Priur!o ifs iaaruwce, ,woi�ort��'ni�i'ito%T(S) _ . . _ _ _ _ ._ aLo,reqriras tlx eppl/mre jor arcb p�mrtt W Ji7e a ; , sigwed rtatmwwt fbai M&Jfuwfed parraaMt to ebe � t�ssroa O oanvEu❑ . .... . . . . . . . . '..'. . . prov:siasr oJ tL.Cowrractor's L4�eat�lom(Cbapter 9 �tha.aer�ix.sEweR ox � .. . . , ' (com�witb Sutiow 70001 oj Divaio�3 oJ eba � SEWAGE DISPO6M SYSTEM . oomw�[cr auc u.�o 8usiaesc a�d P►ofruioas Codr)w tbat bs ic exrmpt ��w«+�ai,se se�a ebere/.nrn oad eb.bm&jor rb.e7l.grd.rn.pe:au.Axy e�ac�i srr�c r,v«s p . '' � rtioraaor ojSetdor 7031.5 h'�J"e?PltcaMt jora p�rmJt . s[r.m s O ai5roas❑-- -- .. . ___�---.. .. .. - _ ..� �. . . -; �'.� .. . . .. srbjaces sb.appJicasr ta e ctoJ p.walsy ojwoo rnore eba+r .... . . . . . . . .. . ... . .- ,-= : ..��._ . ;.'.� . _ live brtulred doJlars(i500�:. ' - �I,as the owner oi t6e propett�tvil!do tLe work,aod ' . � the structure is not inneaded or o�leeed for sale. 1 -- __ _ /Sx. 7044.Brai�us mrd ProJwioMa Cod�:Tb. .ow- � � � . . . - .... . . . ._ . - . . . trmctor's Lkew Lau daer�ot qpply to o�owwer oJ _ . propwty wbo brJJdr w brpmwt tb�no��a�d wbo dws , __ , sYcb+eork binuelj prould�d ebos srcb irsproewrMax# --- � aro�at iwfrMdwf or oJfirrd for wli.I/,Eo�onwr,flw � . . .. .. _ . _ ._._ ... -- . . .: br:ldiwa or ie.pw�wrat ir mld�uisbiw au ysar oj ' . . . _ _... . . ... . .. . .. . ._. . :.-. _ ... :...��. �... . �. nonipAtio�. tb�owr�nbrrHs uul!baw tbe brrdsa __ . _.. ._ __... . __ _.__ _� _ . _ aJ?roww8 ibat,6�did wat baAd or�protK for tbe _ . ... Ar�Do*.9�.,.k•1 . .. _ _.. __ _ . , ..,, _� _ _. .. _. _------.._. _._. � .. �: .. . - - -._IBntC]c2IDQtud�M$EC.'- -- � ' . .. .__ . . . _ .:.:�. . . , ` � . } .. . .. - . � _ . . . - - .. . - � .. . . '�B 8t p.C.f0!t}II�lC8&Oa '�� . _ . ,. — Date - _ Owner ; _ INSPECTOR'S NOTES - . -.. - � . . . � . � - � . - , . , , ,, . . � . .. .. . .t � � � . ._ .... ,� .