HomeMy WebLinkAbout1123A ia WORKERS'COMPENSATION DECLARATION /
,I her.tby affirm �hat I have a certifimte of consent to self _
insure,or p<ertifitate of Workers'Compensation Insurance,or ���E�Z� '�
a certlfied copy thereof(Sec.3800,Lab C.) Cd09�kt�."�31 APPLICATION FOR PERMIT "
Policy No. Company :
❑Certified copy is hereby f�rnished. SEWER - SEWAGE D15POSAL 1 +� I
�Certified copy is filed wi�h the county building inspection COUNTY OF LOS ANCsELES BUILDING AND SAPETY �
dep rtme t.
Do�e��Applimnt BRUCE L. Al3SEY FOR APPLICANT TO FIIL IN CONNECTION�ATA
CE IFICATE Of EXEMPTION FROM WORKERS' eunoiNc
COMPENSATION INSURANCE nooaess 1401 S. VALEVIEinT DR, sTnrioN oevtH
�This seci�on�eed no�be complefed if the work invoived by the MANHOLE REFERENCE UPPER
permit is for one hundred dollars($100)or less.) �ocnurv iowea
i ce�tif ihat in ihe erformance of the wark for which ihis ceosSST GRAND AVE. & SUMMIT RIDGE DR. TYPEOFCONNECIION IENGTHfROM
Y P Y. CURB P.1, M.L TO P.L
permit is issued,I shall na employ ony person in any manner vc No
so as ro become subject to�he Workers'Compensation laws. owNea BIL.�11�L$(A LIMITED m inec.No �os rvo,
D��C Appl�conf� ADDRF.SS 3151 AIRWAY AVE. SUITE N TRUNK PERMIT NO. ROAp PERMIT NO
N�TICE TO APPLICANT: If, after makin ffti5 CEftifiCOt2 Of AFF�DAVIi WANER EASEMENT RECORD INSTR NO DAiE
� �n tion, ou should become sub�e9t to the Workers' ���Y C�STA MESA �`�.TFi No, ]14 $50-1��1
;P Y I t�a�
,iensotion provisians of the Labor rode,you musl forthwith oescaiaiioN ioTNo ].Z Hwv oa sr wioew�v�
comply with such provisions or this permir shall be deemed 42556
revoked. siocK iRACi SiAiE ENCRO9CHMENi
LICENSED CONTRACTORS DECLARATION r�o.oF st�cs. 'ER"ar ra°.
SIZE OF LOT NOW ON LOi
I hereby aifirm�hat I am licensed under pmvisions of Chaprer �' use oF SINGLE FAl°1ILY R�SIDENCE
9(commencing with Section 7000)of Division 3 of the BUSi- BUIIDINGS cwnRc,�s
ness and Professions Code,and my license is in full force and
ef{eCl. •� CONiRACiOR SRARIAL�A. CALIP. INC. CONNECiIONCHARGEFEE
License Number 409610 �iC.CIO55 � REIMBURSEMENT FEE '�
nooeess 3151 AIP.WAY AV�. SUITE N o.
Contractor RRAMAT.F.A ('.AT.'NBte A c� �]1 O 1 OISiRICiNO. GROUP nnnv PROCESSEOBY �
,� CITV CQ.STtf r�."JA CA. TEL NO !14 OS�-10�1 /� 8K P('i �
❑�am exempt under Sec. of the L.A.Co. ' iiCENSE No. Ctn55 �
0
No OESCRIPiION OF WORK r�e
Plumb�ngCodeond/orSec ofthe FiNai �/��/�'/ yq��DATION �
•HOlISE SEWER GY)NNECIING i0 OATE S "
B.8 P.Code for the following reason �UBUC SEWER ], .
$EPTIC TANK,SEEGqGE PIT OR �
PiiS AN�;OR pRAINFIEID FINAL a '� .
Dafe FqUSE SEWER CONNERiNG�O 8V A 1_.__/
PRIVATE DISPOSAI SYSrEM /tl'�++��.r
Signatur�� �• CONNECI AD�ITIONAL BLDG OR
OWNER-BUILDER DECLARA710N woaK To r+ouse sewea
�— OVERFLOW SEEPAGE PIT,�RAINFIELD -. ; - �--
I haieby affirm ihot I am exempt from the Contra License � exrN,cessroo�.oarw¢u.maNNoie i I �:�;
Lnw for the following fP.pSOfl(Secton 7031.5,Buisness and Pro- airea RFPAIR OR A9ANpON HOUSE
� )nS COdC�: SEWEIE OR DISGOSAL SVSTEM „ , � ..
L.I,as owner of the property,or my empioyees wiih wages ds . w�•� �C •
their sole compensation,will do the work and the strutlure ' - � '
is na infended or offered for sole(Section 7044,Business . �; . �
and Professions Code). OWNER'S Permit 5 � �..,{,`:�
I�I,as ow�er of the property,am exd�si�ely contracting with ! AUTHORIZATION TOTAL FEE 27 rj� f;';(1�_�r
licensed contrauors to construct the projeci(Section 7�E4, I HAVE Ai iH15 DAiE A CONiRACf WITH THE HEREiN NAMED CONiRnCTOR TO
Business and Professions Code�. ' CONNEC7 iHE ABOVE DESCRIBED E%ISTING DWELLING TO THE FUBIIC SEYJER '
CONSTRUCTION LENDING AGENCV "�-�- 1 ,
I hereby affirm Ihat Ihere is a conshutlion lending agency , SIGNEDTHIS 7� �AYOF �J J N�-- 19 �
for ihe pe�formance ot fie work for which rhis permit is + owaee oR � � �
iSSUCd(SCC.3097,CiV.C.J. '� OWNERS/•GENi �.��+
Lende�sName TORONTO DOMINION SANIC aooaess �151 AIRW�AVF_ STiTTF, N L�6S7'A N A�CA.
Lender'sAddress S� �CISC�� CA.
I certify that I have read this applimtion and stote that�he
above information is correct.I agree to comply with all Couniy �
ordinances and Stata laws regula�ing Pl�mbing and Sewers,
ond hereby authorize representat�ves of th�s County ro enter
upon the above-mentioned property for inspection purposes.
^���. 0�1.�4.. � ��-a-r
$ignoture of Permillee � Da!e � , SEE REVERSE FOR EXPLANATORY IANGUAGE
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