HomeMy WebLinkAbout1268A (6) ��� WORKERS'COMPENSATION DECkARATiON �
I hereby affirm lhat I hava a cerlificota of conseM to Self
insure,or p certificota af Workers'Compensation Insurance,or �ene+2o ,
OCeY����'��'��`mp��remont IIIdEIILT1I-ty ��IREV.B/81) � �ppl(CATION FOR PERMIT
rar� .
p Certified copy b hereby fornished. SEWER - SEWAGE.DISPOSAL ` . -
��Certified copy is filed wi�h the county ilding inspectio � COUhTY dF LOS ANGEIES BUILDING AND SAF�TY
department.
oo�a�'�1___�__R�pplicanl F�R APPLICANT TO FIlL IN CONNECTtON DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' g�µp�� � � _
COMPENSATION INSURANCE aoouess S�O �S SrAT�r+ oEvt�
. .. . . ...--
(Tbis section need not be complated if tbe work involved by the - - - --- - . : - - . .... . . ... .. u�a
permFl rs for ona kur�ed do}lan�$700)«iess.j iouu itv - ++oie Rcr�a[Nc[ �. _ ...�owee
M4N
. . . . . .._........_._... .... .. .. . . ...__ .. . . NFnRESf� Old....._........ .......... .. .. . .. ..... TYPEOFCONNECf1ON. . .. .._. ...... .
1 certify that in the performance of the wwk for which this CRO555T. IENGTNFiOM
Y. CURB V.l M.L.TO P.l.
permit is�ssued,l shall ndt employ any persort in ony mpnnar � � ' 'I''he Anden �Group P��-^�-
so as to 6ecome s�bjed to Ihe Workers'Compensation Laws. pW�R co�tiv.r�o. ioe uo. �
. ' . - ' hV111- ' " - ' TRUNK fERMIT Np ROAO PERM17 NO.
Dote Applimnt /+DDRE55
� ?ICE TO APPLICANi: If, offer making tf113 Cerfifico�e of ��TY AfF10.4VIT WA:VER EASEMENT RECARD.INSTR.NO. DATE
_mption, �you should become s�bjacr to the Worken'
Compenwfion provisions of the tnbor code,you musl forlhwi/h � pEscpt i�iori irn*m� MWY.Ofl ST.WIOENING
comply with such provistnna e��hFs permit Shni4 oe deemed 42586 �
�eVtlltGfl. - - -- &OCK TRACT� STAiEENCROACNAAENi
—'���5 PFRMIi NQ
, 110ENSED CONTHACTORS DECLARAIION size or ioT Now oN�oT
� 1 hereby offirm ihat 1 am licenaed under provisiona af Chaptar ��
. 9(commencing with Section 7QOQ}of Divisian 3 of ihe 8usi- suuoir�s cHnac�s
, ness and Professions Code,and my ficense is in fult force ond
Qffe��� '- -- ppNTRACTOR CONNECTIONCMARGEfEE
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. - �li@CIS@NlllllbEf._____..Z��J.ILL�QS4__. - _ d
��6---- -- - Aoo�--12385-�4a nfl�ia Av�.-- _ --- ��Ms���. __ _ _ _ _- --- - -- p-
DISTRICT Np. GROUP MAV PRIX'FSSED BY V
Controc�l:R PLITMRII3CiDa�e7J31�8Fi ��iy Riverside iE�.,�.��1-5oao � � Z
0 1 am esempf undeo5oc. . of fhe LA.Co. iiAccnsE No. cinss 1� 0
H
Plum6ing Code and/or Sec. oi 1he �� DESCRI K FEE - �E� U
_ HOUSE SFwER CONNECtING TO W
WBLIf SEWER f t../,..$L
B.8 P.Code for the foilowing reason � V ALID ON �
$EFfIC FANK,SEEVAGE PIT OR
P�TS AND/OR DRAINFIELD fINAL �
��� MOUSE SEWER CDNNECTING TO g�
PRIVAi �ISPOSAL SVSTEM
$19n4fVlB [pryryECT qppR�OpJF[6lDG.(N7 " �
ONINER-BUftDER-DECtARAT10N - w°aK�oNWs�''E'^'ER
OVERFLOW$EEPA(�PIT,ORAINF{ElD �
��ereby affirm that I am exempt from the Contractor's license EXTN,CESSPO�L DAYWELL,MANHOIE _; �`�µ
. . . . ....:.;
for the fol(owing reason(Setton 703L5�Bu150@33 OfIfI P�O- AL7ER,REPAIR OR ABAN�ON IqiJ$E, ' ' ' _ , -
..,sionsCode): ' . . .. sewcaarasrosaisrsrtm.. . � .� ._ .. x,
.. . ._.. ... .. .. . -�- - - -- .. .... . . . . . . . .
❑I,as owner of 1he property,or my empfayees witfi woges as ti' 6�`��� G
iheir sale mmpensolion,will da ihe tvark nnd the strucfure - � x �L� -
�is not infended or offared for sale(Sactian 7044,Business "��
and Professions Code}. OWNER'S Permil S (? Q
❑i,as owner of the properry,am exclusive[y tontracting with AUTHORIZATION 70iA1 FEE - � � _. �' "" e- !.'���"
�icensBd conhOLtors to'Wnsiruct ihe projeCi($eCtion 7�44, I HAVE A7 THIS DATE A CONTRACf WITH 7HE MEREIN NAMEo CANiRAC70N TO 7i C'(_�`:;C:
BUSif12S5 011d PfOfB5310f1S COdO�. CONNECT TNE ABOVE DESCRIBE�E%ISiING�WEILiNG TO THE PUBUC SEWER.
CONSTRUCTION LENDING AGENCY �
I here6y offirm that there is a construction lending agency StGNEDTHtS DAVO� w_
for the performance of fhe work for whith this permif is OWNEROR .
issued(Sec.3097,Civ.C.). �"���'NT
nooaEss
Lender's Name
Lender's Address
I certify thot I have read Ihis applica�ion and sta�e lha�the
abova informa�ion is covect.I aqree to comply with a!I Covnty
ordinonces and State laws reg�lating Plumbing o�d Sewers,
and hereby outhorize represeMqlives of this Cou�ty tv enter '
upon ihe pbOv mentioned io rty fo�inspeciion purposes.
RCR EY; �i�� 7/31/86
Signafure of Permittee Date - _ SEE REVERSE FOH EXPLANAT01tT L�NGUAGE
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