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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 � . . .. .., . � . -. � . , -� • � �s, �n j>c�D�`�,����k t.w:..:,rlri L . ` �„ I de ; y ' ' } �rC �f D:l��'p 1 � �O'�i:]'Z< L 1 t; . ,"L:�� c � .- I � � , ' � � i ; i I , ; ����jgmi`�yl:� ;�'�:^�; �, ;��.. ; ; ; , _� � ! � � ; � � i i y � . . � . . � . ���Cn-, i-' �D' l�vj c" f�i ' ! a S � 'I , . . .� e•:��A I �?�' �^ � '� � , i j i . . �^,--y'�,n��?S� i„T��;r�)� �,�� ;' � � . � i �� . I , r . ,. � . _' . . . �f � ,<Jt�p� z IvLi q f . ,�; i ' ; t ; � � ' i . . � . . . 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