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
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