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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 �:: , ' .a . .. . . . ... . . . . . . .... .. Y',�,'�'4vv1.Do �➢� m �D�n�m�i L**�a,.�.r . -� r��A(1';�an �' IG='OL! � ! i� : . f � I + j ' i . . � � �e �I?���n:o� � ,p(l�7('�Z`F .J � 1 1 ' ; . � �� . � j.. . . 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