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HomeMy WebLinkAbout1124A (5) � ° 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 „ -��-9r��t_..��; ''`'K ' .y5^tGCyt�`4 ��S �'.t � ..� :.7.^1,GZ� S 1� y'T"6,t,':%i°S\ Y'Q•,'c9{'t'Z(�,' �^1� .. ' :��P�,q i,S Y F'\-.`: t A 7,+�' ”. ^'F����. . 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