HomeMy WebLinkAbout0718A (4) WORKERS'COMPENSATION DECLARATiON �
I hereby offirm thm I hava a cer�ificaie of consent to self �
insuie,or a certificate of Workers'Compensotion Insurance,or �erw+xo � �� � �
a certified�o�"�fh�epre��o�f) �,�ab �EdORIREV I/89� ppp��CATION FOR PERMIT �
Policy No P.�..wla_y—"�¢ y �,�/�
❑Cartifiad copy is here6y furnished. SEWER - SEWAGE DISPOSAL - ' �
�„Certified copy is filed wirh the coumy buHdin9 inspecuon COUNTY OF LOS ANGELES BUILDING AND SAFETY
de art nt.
Date �Appliconf- � -�� FOR APPLICANT TO FIIL IN CONNECTION DATA
CE IFICATE OF EXEMPTION FROM WORKERS' suumNc
COMPENSATION�NSURANCE A��RE55 STATION o¢vTH
(This secfion need noi be comple�ed if the work imolved 6y r,wNHoiE REFERENCE uaaea
permit is for one hundred dollors(E100)or less.) 1OCA"TY Di amond Bar LOWER
I cerfif that in the erformance of ihe work for which ihis NEnqeST iYFEOFCONNECTION �FNGTHfROM
v P �RouSrGrand Avenue & Summit Rid e Dr.
permil is issued,I shall nol employ any person in any manner Y NRs a� n�t i ro P.t.
so os to bemme subject to rhe Workers'Compenso�ion LtlwS. OWNER Bramalea Limited v.c No.
p� CU IMG NO JOB NO
Dole Applicanf
ADDNE55 3151 A i rway Ave, 5u i te IY iFUNK PERMIT N0 RDAD PERMR NO
N�TICE TO APPLICANT: H, ofter makin t{tls Certificate of AFFIpAVII WAIVER EASFMENi RECORD,INSiR.NO, DAiE
s ��r� Costa Mesa rE�No 714 850-1001
� 'mption, you should become subjeci ro the Workers' iE�qi
;pensation provisions of ihe Labor code,yoo mus�iorthwith DCSCRiPiIDN ioTNo24
comply with such provisions or�his permit shall be deemed �i`N�ORST WIDENMG
revoked. eiocK TFACT $TAIE ENCROACHMENi
LICENSED CONTRACTORS DECLARATION wo.oF amr,s PERMR NO
SIlE OF lOT NOW ON lOT
I here6y affirm that I am licensed under provisions of Chepter . use oF
9(mmmencing with SeUion 7000)of Division 3 of ihe Busi- evuoiN�s cNaR�es
ness and Professions Cade,and my license is in full force and •
effect. co�viannou Bramal ea Cal i f., IIIC. coNNeciioN cHnao[ree
L¢ense Number 4(l�](1 lic Class$ �"
�+ t AU�RfSS REIMBURSEMENi FEE �
ConiroCtO�ramal ea 1+a��i pOte 6/6/85 � Costa Mesa rE�N0 71 85�-1��1 DIS�RI�T NO GROUP MAP PR(XESSEO BY y
��tY //�` BK PG
❑I om exempt�nder Sec. of the l.A.Co. uC¢Nse No 409610 �lAss g `U � �
Pl�mbingCodeond/or$ec, ofihe No DESCRiPTIONOFWORK FeE FiNai . �•• a
HOUSE SEWER CONNECiING 70 DATE � VALIDATION W
B.8 P.Code for ihe following reason � PUBLIC SEWER �'7J 'f--//-�,� 4 i
SEPTIC TANK,SEEPA�PIT OR � �
PITS AND/OR DRAINFIfL� FiNA` � �
DOtC HOUSE SEWER CONNECTING TO BY �
� — I. ^�Q ^ PRIVAiE DISPOSAI SYS7EM L� `
Signafure '7--- 'il�� l� ✓; CONNECT ADDIiIONAt BI�G OR , �
O NER�BUILDER DECLARATION '�`/ORK TO HOUSE SEWER �
OVERitOW SEEP0.GE P17�RnMFIElO '
I hereby affirm that I am exemp�from Ihe Conlract ' nse exiN.,cessvooi,oRrweu,mnNHoie ,
Law for the following reason(Secron�O37.S,BUIS. Ottd PIO- AIiER.REPAIR OR A9AND04 HOUSE
in5 COde�: SEWER OR DISGOSAL SYSTEM _ �
u I.as owner of the property,or my employees with wages as
iheir sole compznsation,wili do the work and ihe sirutlure z 0 7 t 8 A
is not intended or offered for sale(Section 7044,Business
and Prafessions Code). OWNER'S Pe�mif S lid tS71 �
❑I,as ownei ot the property,am exdusively conrracting with AUTHORIZATION TOTAL FEE �. �7� #e • r e � Q
licensed rontroc�ors to consirucl fhe projec�(Seclion�044, I HAVE AI iH15 DAiE A CONTRACT WITN iHE HEREIN NAMED CONTRHCiOR i0 � *� 4 G�,J�
BUSif1C55 Ofld PrOfESSIOnS COfJC�. CONNECi iHE ABOVE DESCRIBED E%ISTING�WEILING i0 iME PUBLIC SEwER
CONSTRUCTION IENDING AGENCY � s e
e27.50�
I hereby aNirm ihat ihere is o wnsiruction lending ogenCy SIGNEDTHIS D DAVOF i ► , .
for ihe pe�4ormance of Ihe work for which this permit is ��'/NEk y Q(�� Q�8�j
OWNERS AGEN
issued(Sec.3097,Cir.C.).
lenders Nome Toronto Dominion Bank ADDRESS
Lender'sAddress San Fransisco
I terfify ihat I have read this applimtion and stata that ihe
above informalion is mrrect.1 agree to mmply with all County
ordinonces and 5tate laws regulating Plumbing and$ewers,
and hereby authorize representatives of this County to enler
upon the above-mentioned prOperly for inspection p rposes.
g atu�e of Permittee Dale SEE REVERSE FOR EXVLANATORY UNGUAGE
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