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HomeMy WebLinkAbout1125A (5) ' WORKERS'COMPENSATION DEC�ARATION ' � - . - .I hereby-affirm that I have a cenificme of consen� ro self � insure,or a car�ifico�e of Workers'Compensation Insurance,or rnnw�u a certified copy ihereof(Sec.3800,Lab C.) , cr eue;e�v.va3i qpp��CAT1�N� FOR PERMIT t��� Policy No. Company � ❑Ceriified copy is hereby furnished. SEWER - SEWAGE DISPOSAL "�� . �Certified copy is 4iled with the couny bu�lding inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY depa tmen. � Date��Applicont BRUCE L, AEBEY FOR APPLICANT TO FILL IN CONNECTION DATA CER IFICATE OF EXEMPTION FROM WORKERS' ewioiN� sranoN oearN COMPENSATION INSURANCE ADDRE55 (This sechon need not be tompleted if the work involved by the �o�A�,ivDIAMOND BAR r^^NHo�e aereeENCe UPPER permit is for one hundred dollars($1D0)or less.) �awER � I certify that in ihe performonce of ihe work for which this c"RosssrGRAND AVE. & ST.TML�ZI`l' RInGE DR.. Tva�occoNtieCnOrv �N�rnpxom permi�is issued,I shall nof employ any person in ony manner Y cURB P i on.i ioP.t. so as to become subjec�to ihe Workers'Compensation laws. owNee BR.E�t'"1L�LEE� LIMITED co i,�nv No ioe No ��� TRUNK PERMIT NO. ROFD PERMIT NO Date Appl�cant nooaess NOTICE TO APPLICANT: If, afier making iflis Certificate Of AFFIDAVIi WAIVER EASEMENT RECORD INSTR NO DAiE ' �pnon, you should become sobject to the Workers' aTr COSTA M�SA�CArei No(�14� 8$0-1001 � ensolion ovisions of the Labor code, ou must forlhwith �ECA� P p� Y DESCRIPTInN lOi NO HWY,pk ST WIOENING mmply with such provisions or�his permit shall be deemed �¢YDkP.d. BLOCK IRACT 42556 SiAi[EN[R09CHMFNi LICENSED CONTRACTORS DECLARATION rao oF eiocs FERMIi NO I hereby affrtm that i am licensed under provisians of Chopter SizEOFiOr NOw oN iot � `"SEOF SINGLE FAliILY RESIDENCE 9(commencing wi�h Secrion 7000)of Division 3 af the 8usi- awio�N�s anaces ness and Professions Code,and my license is in full force and CFfECi. CONikACTOR BR(�iI'�IALEA CEILIE. INC. CONNECiIONCHARGEFEE k license Number 409610 �ic.Class B , °�- ! �.,• ��`. •�/ �/" � AODRF55 REIMBURSEMENT fEE 1 COntfOCtof�'N�1��4 M�.I�Ote �� [rFC�V 4 DISTRICi NO GROU� MnP PROCESSE�BY O nrr COSTA I✓ESA rE�No. 714 850-1001 V ❑I om exempt under Sec. of the L.A.Co. STniE 40 610 Cia.55 $ �� eK � � IICENSE NO, No. oescairrioN oF woRK Fee Plumbing Code and/or Set. � of Ihe .Hpuse sewee coNNecriN�io F�A� ,�/ � �/ALI AT�DI� � uVi OATE B.8 P.Code for fhe tollowing reason. __ Pueuc SewEa ��, �S � � SEPTIC*ANK,SEEGAGE PIT OR y DOtO PIiS AND/OR DRFINFIEL� gNA� 9 � z MOUSE SEWER CONNECTING TO � � PRIVAiE DISPOSAL SYSiEM ��'ltit.0 $i(jnqtUfe � CONNECT ApDITIONAL BLOG.OR , , OWNER-BUIL�ER OECLARATION woaK To Nouse sewea OVFRFLOYJ:kFPA('iF PIT DRAINFIEID �' '�� I hareby affirm ihat I om ezempi from ihe Conirocior' ' nse � � ¢zTN.CESSrOOt,�avweu,rov.NHoie Law for the following reason(Secton 7031.5,Buis ss d Pro- . aireW,epaa�a oe nAo.NooN Nouse '� iiOns COdeJ' � SEWER OR OISGOSAL S'lSTEM ' �J�I,os owner of the property,or my employees with woges as � iheir sole compensation,will do the work ond the structure � i � L v Fl is not intended or offered for sale(Section 7044,Business " and Professions Code). OWNER'S Permit $ �; , s , �� �, � �I,as owner of the property,am exclusively conrracting wuh AUTHORIZATlON TOTAI FEE [�/� licensed contractors to consiruct the project(Se�tion��44, 1 HAVE AT iH15 DAiE A CONiRACi WITH iHE HERE�N NAMED CONTRACTOR TO � g �����J 1: BUSi�055 PnCJ PrOfe55ion5 COde). CONNECT iHE A80VE DESCRBED EXIS71NG DWELIING TO THE GUBLIC SEWER. ' CONSTRUCTION 1EN01NG AGENCY '�'S3. A � _����I:;:Q�; I hereby affirm that there is a construction lending agency SIGNED THIS 'Z� --6AY OF „S�1N�—� 79� for the performance of the work for which this permit is owNea oa � 1'�,l�G`�v � ISSUQ(J(SEC.3OJ7�GY.C.�. OWNERS AGENT rw-- �� RDORE55 I Lender's Nome ToxonTzo nor�rNiaN Rarrrr _ . I Lendar'sAddress SAN rRANCLSCO, CA. I certify that I have read this applimtion and state that�he i above informalion is mrrect I agree to comply with oll Couniy , ordinances and Sfafe laws regulating Plumbing pnd Sewers, ' �, and hereby aulhorize representofives of fhis County lo enter . � upon ihe obove-memioned properiy for inspetlion purpose. � �._a..-a.+..a- �1..`^.'t✓` �_(�("Q/O„� 5 gnalure of Permiltee Date- ( � SFE REVERSE FON EXPLANATORY IANGUAGE ' � � � , , � . . . .�'��ne��>�sr��{b��mr•.`..'.,._-,,. m cp, ' ` � + E i ( I ; t ' ��T�Z^p�>;o� � �G�;o7 i '�Fi i � i� I � . � � ! 1 ; : � �_s .,;�z M;�: � : ���m; ' ; '� �' I � ,{ , i i : � , f . ' . a<. ,ii1i na, j�D����', � �r' k I � I ! + � � i . ; { ,�,t;,�,=t;!=�j ��I`x�.vi ,''�j . ! � I � � .i ! i � . , ;'�i,�,c)_.'U�V I � �2T'�o� i•Q :� { � � I i � � � � } � . ' . . _' .. f)1r. 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