HomeMy WebLinkAbout0892A (6) � WORKERS'COMPENSAiION DECIARATION
I hereby affirm that I have a certifimte of consent to self 9zmox orw oie� A
insure,or a certiticple of Workers'Compensation Insurante,or ��b°�0 ��
o certitied copy thereof(Sec 3800,Lab C.) `E a°a qppLICATtON FOR PERMIT , 1S
Policy No-. Compony 0s
�Certified copy is hereby furnished. SEWER - SEWAGE D{SPOSAL
�Ce�tified topy is filed with 1ha couniy building inspection COUNTY OP LOS ANGELES BUILDING ANDSAFE7Y
deparGnani. . .
Dore g_�}�__nPPu�ani FOR APPLICANT TO FILL IN � CONNECTION DASA
CERTIFICATE OF EXEMPTION FROM�WQRKERS' euuan� STnnoN �mH
COMPENSATION�INSIIRANCE aoDaE55 ZO Z L39�r R1ID LallB
(Thia sec�ion need not 6e completed if the work involved by the i���T� �j.ymOnd B2� n�wNNaE REFERErxE f ,� / �
pe�mif is for one hundred dol(ars($100)or less.) ' (�/
1 cerfify that in 1he performante of the work for which this CRp�SgT M40FCANNECTION � {pI�iMFROM � �
pe�mil is issued,1 shali not employ qny pergon in any.manner Y� cuue v.i. n+.t.ra v.e. �..i
m us�0 6ecome subject to�he Worken'Compensoleon�owg. P�C���
OW�� CO.IMP,NO,
JOB NO.
M411 TRl1NR PERMIi NO. RpAP PEpM1T NO.
Dofe Applicanl nooREss
NOTKE TO APPIICANT: If, after moking �h15 CeffiflCafe Of ��Ty TEI.NO. AFFIDAYIT WANER EaSEM[NT RKORD.INSiR,NO. Q4TE
Exemption, you shauld become subject ro �he Workeri �E�ai
Compensaticn provisions of�he la6or code,yov must forthwith �scaiorar� �aT No. Hwv oR sr.wioe�vwc
camply with such pravisions or th�s permit shall be deemed �g24 �
revokad. aiock TRACi SrATEENCROACHMENT
UCENSED CONTRACTORS DECLARATION r�o.o��ocS. a�RM�r rvo.
S�2E OF LOT NOW q4 lOT
f hereby affirm lhat I am licensed under provisions of Chopter 7 ..
9 cammencin with Section 70W.. f.pivi9ion 3 of ihe 8usi- ���
( Q �0. BUIIDiNGS �GS• CMARGES
ness and Professions Code,and my license is in fuil force and
9Sf0CY. q (Y [pNTRK�Op � Ofl CONNEC710N CHARGE FEE
LICelISB�`7uT������+ LjC,C�O55 v4� qDDREiS 1 Hamner Ave. A REIMBURSEME�iT fEE 1
COlItNC�O Date �I�A �ISTRICT NO. GROUv MqP PROCESSEO BY
dan i�ieat f�� 7 ��.., Norco ,E��734-7�42 BK � Z
❑1 am exempt under Set. of the LA.Co. SrpSE °�. � ''
IICENSE NO. 68 C1A55 C 2 � � 0
Plumbing Code and/or Sec. of the � DFSCRIGTION OF WORK �E HNA� � V
r�aeui c��R coNNecriNc ro oare �,,{J„.�cy VALIDATION y
B.8 P.Code for tha following reasan - Q V (�
SEVTI�TANK,$[EPAGE PIi OR fA
DOtB �TS ANO.�OR 02AINFIEID FINAL Z
� IpVSE SEWER CONNECfING TO 8V
PRIVAiE DISPOSAL SYSiE
$191tO1uIE CONNECT A�DITIONAL BIDG.OR �
OWNER-BUILDER DECLARATION WOBK TO HOUSE SEWfR
� I herab affirm fhaf i am exam t from Ihe Controcfor's License OVEkF�Ow 5[ePa.�e cn,oaawriem
Y P E%iN.,�SSPOOL,DRYWEIt.MANMOIE
law fw the fol4owing reason(Sec�on 7037.5,Buisness and Pro- ur�a,aevaa ou wanNoor��pus�
fB5510f18 CO(IB�: SEWER OR DISPOSAl5Y5TEM
�
' ❑I.as owner of�he property,or my employees with waqes os
. their sole compensotion,will do the work and the sirudure
is not intended or offered for sale(Section 7044,Business �C�5'r.L t+.
ond Profess�ons Code). QW(�j�(j'$ Permii S
❑1,as owner of ihe property,am exdusively con�mcting with AUTHORIZATION �TOTAL FEE �• • • • � �' '�'�
� licensed contractors to construcf the project(Section 7044, �HAVE A7 iH15 DAiE A�ONTRACf WITN THE NEREIN NAME�CONTRACTOR i0 � • •��,�(? I
. BUSif1E55 O/l(�PfOfB5410n5 CO(IE]. CONNECi TNE ABOVE DESCRIBEO EXIS7ING�WEIIING TO iHE PUBI�C SFWER.
CONSTRUCTION LENDING AGENCY �
I hereby offirm }hat there is a mnsiruction lending agency SIGNE�THIS DAY OF I9,_ � � � �2�.����
for Ihe performance af the work for which ihis permit is OwNEkOk
OWNERS AGENT I
ISSIIBd(S@C.3�7,[IV.�.�. r l!.C ..
PD�RE55
Le�der's Name -
Lender's Addreu
I certify that I have reod this application and siale that the
obove infwmation is correct.I agree to comply wi�h alf Coun�y
ordinances and State laws regulafing P�umbing ond Sewers,
ond hereb authorize represenfotives of this Coonty to enter
. upon th �ova-mentioned ro erty for inspection purposes.
�/,a.,�. �n� -3/�r�
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