HomeMy WebLinkAbout1126A ' WORKERS'COMPENSATION DECIARATION �
.i hereby af4irm that I have a ceitificate of coasent �o self � }"�
insure,or a cenifimre of Workers'Compensation Insurance,or '�^6a2� � II
a cerfrfied mpy ihereof(Sec 38D0,Lab C.) CFQOd;REV I/p9� APPLICATION::FOR�PERMIT °
Policy No. Compony SEWER - SEWAGE DISPOSAL � E
❑Cer�ified copy is hereby furnished.
�Cen�fied copy�s�iled with�he coumy building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
depa tmen.
Oate�?�plicani RRiTCF. T,_ APRRY FOR APPLICANT TO P�LL IN CONNECTION DATA
CER IFICATE OF EXEMPTION FROM WORKERS' auimiNc 141 S. VALEVI�Tn� srnnoN oevrH
COMPENSATION INSURANCE AnoREss
(This section need not be completed�f�he work involved by the iaAiirY DIAMOND BAR ^naNHae aereseNce UPGER
permN is for one hundred dollors($100)or less.) �awek
NEAREST TVPE OF�ONNECTION IFNGTM FROM
I cerf�fy tha� �n the performance of ihe work for which this ceoss sr y, ��gg P i M.i.to P.i.
permi�is issued,I shall not employ ony person in any manner � a c No
so os to become subject ro the Workers'Compensmion Laws. owNER BRAMALEA I,IMITLD CO IMP.NO. JOB NO.
M4II TRUNK PERMIT NO ROAD PERMIi NO.
Date Applicont ADDRE55 1 1 AIRWAY AVE. SUIT� N
NOTICE TO APPLICANT: If, after makinGJ iftls Certificale Of CITV COSTA MESA,CA.TEI N0�71�� $5�-1��� AFFIDHVIi WAIVER EASEMENT RECORD INSTR.NO DAiE
� 'mplion, yov should become subject to ihe Workers' LEGAI
.�pensation provisions of the Labor code,you mus�forthwilh �FSCRIPiInN LOTNO 1 HWY ORST WIDFNING
comply wifh such provisions or ihis permit shall be deemed
revoked. eiOCK TRACT 42556 STAiEENCRUACHMENT
��81�5 PERMit NO
UCENSED CONTRACTORS DECLARATION sveov ior Now ora ioT
I hareby affirm tha��am licensed under provisions of Chapler use c�
9(mmmencing with SeUion 700p)of�ivision 3 of ihe BUSi- BUILDiNGS INGLE FL�MI7�Y R�SIDEIVC.I'i� CHARGES
ness ond Professions Code,and my license is in fuil forca and T /�
CIfECf. �ONiRACTOR g�LEA CALTF• LNI+. CONNFClION CHARGC FEE
License Number 409610 �iC.[�055 B __ Ap�RE55 3151 AIRWAY AV�. SUITE N REIMBURSEMEM FEE
�._,. �
�OhtlOC101 PRAMATFA ('QT�IC� J arYCOSTA MESA,CA. iEl.NO (714) 850—L001 DISTRICTNO. GRWP MAG GRUCESSEOBY o
G� BK PG �
S1ATE UC
I am exempt under$ec. of the L.A.Co. uCENse No C�n55 �
No_ OESCRIPTION OF W02K FEE �
PlumbingCadeand/orSec. otihe fiNAi q, � / VALIDATION ~
HOUSE SEWER CONNECTING i0 DATE
e.&P.Code for rha following reason PUBLIC SEWER 1] 00 � ��„ a°S �
$[PiIC TANK,$EEPAGE PIT OR F�NAL ♦ ��
Dafe P�TSAND/ORDRAINFIELD B� � y
HOUSE SEWER CONNECTING TO S wi{,C+fJ ?
PRNFTE�ISPOSAt SVSTEM
$igna�ure '"� �• WOkKE O HOUSE�SEWER�DG.OR ►
OWNER-BUILDER DECLARATIqN ovEzviow seean,e aiT�RAWFlELD
I hereby affirm thal I om exempt from the Contractor' e e EXiN,CESSPOOL,�RYWEII,MHNHOIE
lnw far the following reason(52Ct0lI 7031.5,Buisnes d Pf0- AtTER,REPAIR OR ABANDON HCVSE
`yiUn3 COCIE�, SEWER OR�JIS°CSAL SVSTEM
��,as awner of tha property,or my employees with woges os
their sole compensation,will do the work and the siructure z j '; >,'p f�
is noi�mended or offered for sale(Section 7044,Business
and P�ofessions Code). OWNER'S Permit E 10 50 #a '., � � � U
�,I,os owner of rhe properry,am exclusively comraaing with AU7HORIZATION TOTAL FEE l (
litensed contrac�ors to constr�ct ihe project(Section 7044, i Mnve nr rHis�ATE A CONiRACT WITH iHE NEREIN NAMED C I TRACTO ' f �L �J"'
BuSinCSS On(I PrOf25SIonS COCIB�. CONNECT THE ABOVE DFSCRIBED E%ISTING�WELUNG 10 iHE PUBIIC SEWER _
CONSTRUCTION LENDING AGENCY �- �' °' "� �������%
k I hare6y affirm fhal Ihere is a mnsiruclion lending agency SIGNEDTHIS � �DAYOF�uv ` 19_ F,
I for �he performonce of �he work for which this ermit is OWNER OR -^� a� � , �'�,(;c—�5,�
I P OWNERS AGENi
issued(Sec.3097,Civ.C.). aooaess 3151 AIRWAY SIIITE N C ' A P4ESA CA
I tender's Name TORONTO DOMINION BANK
Lender'sAddress SAN FRANCISCO� CA.
I certify that I have read this applimtion and state tha�the
obove info�mation is correct.I ogree to comply with all Counfy
ordinances ond Slale lows regulating Plumbing pnd$ewers,
I and hereby aufhorize representatives of fhis County to eMer
upon 1he above-mentioned prOperty for inspection purpose.
� �otu�er�ee aie SEE REVERSE FOR EXPLANATORY LANGUAGE
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