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HomeMy WebLinkAbout0732A WORKERS'COMPENSATION DECLARATION '�7 � I hereby affirm that I hove a certificute of consent to self � �� insur•e,or a certifimte of Workers'Compensotion Insurance,or �bAb"Z� � � ` a certified co thereof(Sec.3800,Lab C.) �E�R�RFv.,,e�, � qpp:LICATION F�OR PERMIT � aoi;�Y No. 6�1�IBRK4�a�Y Hartford Grouo ❑Cer�ified copy is hereby furnished. , �. . SEWER - SEWAGE DISPOSAL '�� �Certified copy is t�led wlth�he counry bu�iding�nspection COUNTY OF LOS ANGELES BUILDING AND SAFETY dep rime t Daie�O�Applicanr FOR APPLICANT TO FILL IN CONNECTION DATA CE TIfICATE OF EXEMPTION FROM WORKERS' sunoiNc COMPENSATION INSURANCE � nooaess STATION DEPTH (This section need not be complated if Ih�e work.involved by� e \ AMNHOLE REFERENCE UPPER permit is for one hundred dollors($100)or less.)� toCnurv D1 dfl1011Cl BdP �oweu I certify thm in rhe performance of the work for which �his �EROSSSST TYPEOFCONNEQION �ENGTHFROM Grand Ave. & Summit Ridge Dr. �, �„Re P.L MLTOPL. permit is issued,I shall no1 employ any parson in any manner � so as to 6ecome subject to the Workers'Compensalion Laws. owNeR Bramal ea Li mi ted co�Ma NO. JOB NO Date� � � Applicont �' � qpopEu 3151 Ai rway .Ave, Su i te N TRUNK PERMIT NO. . ' ' ROAD PERMIT NO NOTICE TO APPLICANT: If, affer making �IliS Cenificate Of �' CIiY 714 850-1001 AFFl�AVIT WANER EASEMENT RECOR�.INSTR.NO DATE ' '�plion, you should become subject lo the Workers' COStd Mesa re�.No ensation rovisions of ihe La6or code, ou must forthwith �EGA� 38 . P P Y � DFSCRIPiION LOTNO. HWY ORST.WI�ENING comply w�th such provis�ons or rhis permit shall be deemed , revoked. � � etocK ikACi STATEENCROACHMENi NO OF BLOGS PERMIT NO UCENSED CONTRACTORS DECIARATION size oF ioT Now oN ioi I hereby affirrri that I am licensed.onder provisions of Chapter use of none 9(commencing with SeUion 7000')of Division 3 of fie Busi- BVILDINGS �HARGES ness and Professions Code,and my license is in full forte and r `E1ffC1. CONTRACiOR Brama 1 ea C11��f.� 1 nC. CONNECiION CHARGE fEE �License Number 409610/� Lic.Class gpC aDDRESS i rway AVe.� 5u i te N REiMBURSEMENT FEE p°�,� Bramalea l.(���� 6/7,OJ • �ISTRICTNO GROUP MAP PROCFSSEDBT o 'COntfOC�or 01e CITV C 7E1.N0. . — 8K PG � P LICENSE NO 409610 °C B �"� 'Q I am exem t under Sec. of ihe L.A.Co. an5s NO DESCRIPTION OF WORK FEE t� � � � PlumbingCodeand/orSec. ofthe FINAL �//�LIDATI�N uVi� MOUSE SEWER CONNECTING TO � �y q DATE � (' � vUBUCSEWER ti�} 7^ �� � B.&P.Code for the following YCOSOn $Epi�C TANK,SEEPAGE FIT OR � PIiS AND/OR DRAINFIELD FINAL Date FqUSE SEWER CONNECTING TO eY ����� PRIVATE OISPOSAL SYSiEM Signoture CONNECT AODITIpNAI BLDG.OR � NER-BUIIDER DECLARATION wORK TO NOUSE SEWER I hereby affirm that I am exempt from the Contractor's Licen e O�VEJFLO�P�iGDRYWEDl1AMANHoie 'LOW f0/tllC SOIIOWiII(J lE040f1($BC�On 7031.$,BVi511C35 Ond Pf - AITER,REPAIR OR ABANDON HOUSE �qn5 COdEJ: SEWER OR OISFOSAlSYSTEM �u�,as owner oi ine proper�y,or my empioyees wi�n woges as � their sole compensation,will do fhe work and the strutl�re is not in�ended or offered for sale(Section 70G4,Business and Professions Code). OWNER'S Permit b �C`, Q ❑1,as owner of the property,am exclusrvely mntracting with AUTHORI2AT�ON TOTAL FEE �� (� licensed contraciors to cons�ruct ihe projeci(Sec�ion�044, I HAVE A�THI$OAiE A CONTRAGT WITH iHE HEREIN NAMED CONTRACTOR i0 � ' BUSin955 tlnd Prof25510n5 COCICJ. CONNEC7 THE ABOVE�ESCRIBFD EXISTING�WELIING TO THE PUBUC SEWER �.0 7 S,2 A CONSTRUCTION LENDING A6ENCY �� �N� � � I hereby affirm }haf there is a consiructian lending agency SIGNE�THIS �AYOF 19 ► � A p.� ' (� �for the performance of the work for which this permit is �NEROR owNERs nc,cwr ��%�� �issved(Sec.3097,Civ.C.). ' a Toronto Dominion Bank ADDRE55 Lender's Name � � a.� �27,50� ��endersadd�ess$�n Franci$�n �I certify that I have read this application ond state that the � ��� �l"�Jr 'above info�mation is correct.I agree to comply with all County �ordinances and State laws regulating Plumbing and Sewers, and hereby autho�ize representa�ives of ihis County to enter upon the obove-menlioned property For inspection purposes. � Signafure of Permiltee Date SEE REVERSE FOR EXPLANATORY IANGUAGE ...,-�,.,�-.:- - ,.r-.-.., :�`�'".. --, . -• �� - �:---: . ... . — __:��.,... ,... . , __ _ _ - .....w,.::,. � ,.., I ... . . �_ � `ir� ,. ,� ' yn"_iu :' ^ i�-�c�1cO� mi ` ._. _ .... . 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