HomeMy WebLinkAbout1124A � ° WORKERS'COMPENSATION DECLARATION �
.I hereby affirm that I have a certificate of consen� lo self � ' j�
insure,or a cerfificate of Workers'Compensation Insurance,or �enono II
� a certified copy thereof(Sec.3800,Lab C.) �E FOA�RE�„e=, qpp��CAT10N, FOR PERMIT � �
Policy No. Company
❑Certified�oPY is heraby furnished. SEWER • SEWAGE DISPOSAL ,�
�Certified copy is filed wirh the counry building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
de �me
Dote App�iconi BRUCli L. A$B�Y FOR APPLICANT TO FILL IN CONNECTION DATA
CE IFICATE OF EXEMPTION FROM WORKERS' auumNc
COMPENSATION INSURANCE ADDRE55 1405 S. VAL�VI�[a' DR. srnnoN �arN
(This section need not be completed if the work involved by ihe MANHOLE REFERENCE UPPER
permit Is for one hundred dollors($100)or less.) LOCA��TY DIAMOND BAR tow¢a
I ceriify thm in �he performance of the work for which ihis cRosssr GREII�D L�VE. & SlJP�'TIT RIDGE DR. *��oFco�n,ecr�oN �n�tnFaorm
permit is issued,I shpll no�employ any person in any manner Y NRB N.i. M.l.io v.L.
so as to bacome subiecr to rhe Workers'Compensar�on Laws. owNex BIZAMALEA LIMIT�D co�mv No JOB NO
�'�� iFUNK PERMIi NO ROAO PERMIi NO
Date Applicom aooeess 151 AIRWAY AVE. SUITE N
NOTICE TO APPLICANT: If, after maki� ihi5 Certifimte Of $5�-10�1 AFFIpAVIt WANER EA54MENT RECORD INSTR NO DAiE
9 arv COSTA MESA CAaei No(714)
� 'rptian, you should become subject lo the Workers' LEGAI
;pensotion provisfons of the labor cade,you must forthwith DFSCRIGtION �OT No. 1.3 Hwv ox Sr wioeNiNG
comply with such provisions or this permi�shall be deemed
revoked. oiocK TRACT STAIEENCR09CHMENT
�Of g���S PERMIT NO.
LICENSED CONTRACTORS DEC�ARATION size oF�oT Now oN ioT
I he�eby offirm that I om I�censed under provisions of Chopter use oF
9(commencmg with Section 7000)of Di�ivon 3 of the eusl- eunowcs SINGLE PAMILY RESIDENCE cHnacEs
ness ond Professions Code,and my license is in f�ll force and
eFfe[�. CONiRACTOR BRAMALEA CALIF. INC. CONNECTIONCNARGEFEE
ucense N�mbe� 409h 10 tic.Class nonaess 3151 AIRWAY AVE. SUITE N aeimeoase'neNT r�e y,
COf11�qCt0��`�M�L�A CALIFDate �- � DISTRICT NO GROVP MAP GNOCESSED BY �
aTv C A CA iE�.No 714 850-1001 gK � v
❑I am exempt under Sec. of the L.A.Co. iicEnEise No 409610 class B �� a
Plumbing Code ond/or Sec. of the "o �ESCRIPTION OF WORK Fee FiNai O
HOUSE SEWER CONNECTING TO DATE q VALIDA ION
8.8 P.Code for the following reason vueucsewea 1� �� '/ �„y/�;� � �
SEPTIC 7ANK,SEEPAGE GIT OR FINAI o" '
PITS AND/OR DRAINFIELD n y
Date HOl/5E SEWER CONNECiING TO BY � �
PRIVATE OISPOSAL SVSiEM
SiQ�OtUfB ' CONNECi ADDITIONAI BLOG OR ,
OWNER-BUII,DER pECLARATION woeK ro nouse sewee
OYERFIOW SEEPAGE Pli,DRAINFIEL� � �� ���
I hereby affirm tha�I am exempt from the Conna r Licen exrN,cessvoa,oavweu,rno.NHoie �
Law for rhe follow�ng reason(Sedon 7031.5,8u�sn and Pro- nirEs,aecn�z oa asaNppN Hous[
iOnS COCJe�: SEWER OR�ISPCSA:SYSiEM
�I I,as owner of the properly,or my employees with wages as � �f 1 ��!� �� �
Yhei�sole compensation,will do Ihe work and ihe sirutture , � o .�'� �}
is nat intended or offered far sale(Section 7044,8usiness permit $ IQ rj� r a
and P�ofessions Code). 0�11NER�5 � W n r`��G
�1,as owner af the property,am exdusively comracting with AUTHORIZATION TOTAL FEE _ _
(icensed coniraclors to constr�ct ihe ro ec� Secfion 7044. � � . �'-�
P I I I MAVF AT THIS DATE A CONTRA�t WItN THE HEREIN NAMfp CO T ACiO O �- . -
Business and Professions Code�. CONNECT THE A90vE DESCRIQED E%iSTiNG DWELu G TO THE 4UBIiC SEWER. , � �
CONSTRUCTION LENDING AGENCY '('�L—� , 0 7.0�—S 5�
I hereby affirm �hat �here Is a mnstrucrion lend�ng agency � SIGNEDTHIS�p=DAVOF JN�" �
for the erformance of the work for which this ermit is �>`/�'NER VR � „�r
P P OWNERSAGENT �
issued(Sec.3097,Civ.C.). aooa¢55 31$1 AIRWAY SUITE N COST CA l
�ender's Name TORONTO DOAIINION B[\NK i
Lender's Address SAN FRANGISCO CA
I certify that I have read this application and sta�e that the
above information is correct.I agree ro comply with all County '
ordinances and State lows regulating Plumbing and Sewers,
and hereby authorize representatives of this County ro eNer � .j
upon the above-mentioned property for inspection purposes. '�
f ' I
�. A� � �
ISignature of Perm�Mee ��at� � SEE REVERSE FOR EXPLANATORV LANGIJAGE
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