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� ` WORKERS'COMPENSA710N DECIARATION
.I hereby offirm thot I have o cerlifica�e of co�sent to self
insure,or a ceitificate of Workers'Compensalion Insurance,or �snsaz� '�j
acertifiedcopythereaf(Sec.3800,tobC.) �E$�R�Rrv-�,d�, qpp��CATION .FOR:_PERMIT ((p �
Polity No. Company ,
❑Certified mpy is hereby furnished. SEWER - SEWAGE DISPOSAL ,
�Certrfied mpy is filed with the mumy building�nspecron COUNTY OF LOS ANGELES BUILDING AND SAFETY
dep ime
Dare jF�,CApplicant BRUCE L. AE$EY FOR APPLICANT TO FILL IN CONNECTION DATA
CE IFICATE OF EXEMPTION FROM WORKERS' auiioiNc
COMPENSATION INSURANCE nooeess 5iniioN oEriH �
�This section need not be completed if�he work involvad 6y ihe �o�n�,rr DIAMOND BAR MANHIXE REFERENCE UPPER
permit rs for one hundred dollars($100)or less.) LOWER
I certify ihal in Ihe performance of ihe work for which Ihis c"RoSsss'r.GRAND AVE. & SI7NIfdIT RIDGE DR. T�a�orcor+Necr�or, �ENGTMFROM
permil Is issued,I shall not employ any person in any manner �� Cues P.l. M t*p p.i.
so as to 6ecome subject to the Workers'Compensa�ion Laws. a.c No.
owNea BRAMALEA LIMITED m iMv No ,oe No.
Dafe ApplicaM nooaess 3151 AIRWAY AVE. SUITE N TR�r+KPeaMirNo, aon�a�aMiTNo.
NOTICE TO APPLICAN7: If, ofter mokin f{tls Certificote Of AFF!DAVI7 WAIVER EASEMENT RECOR�.INSTR NO DATE
9 aTv rei No 1 8 0-1001
" `nption, you should bemme subject io ihe Workers' �
,ipensation provisions of the Labor code,you musi farthwith oe5caiai�ioN iotNo HWY ORST.WIDENING
� comply wi�h such provisions or this permil shall ba deemed
re�oked. eiocK iRACi 42556 SiATEENCROACHMfNT
LICENSED CONTRACTORS DECLARATION nl(�OF Bt�GS vERMIi NO
SIZE OF tOi NOW ON LOT
I here6y affvm that I am licensed under provisions of Chopter use oF
1 9(commencing with Section 7000)of Division 3 of the Busi- sunowC,s SINGLE FAMILY RESIDENCE I aneces
ness and Professions Code,and my license is in full force and �n n
� CffOCf. CONTRACTOR B�A,LEA CALIl. INIG. CONNECTION CHARGE FEE
LkenseNumber 6f1Qhi(1 LicClass Y�
F p ADDRE55 3151 AIRWAY AVE. SUIT� iV REIMBURSEMENiFEE Q
� ContractorBRAI`'IALP,A CALIPpp�e p�_ ��rY TEL NO, OISTRI�T Np GROUP MAP PROCESSED BV V
f. ❑I om exempt under Sec. of the L.A.Co. SiATE uc aK v� �
uceNse ruo 409610 u.oss B C�
�ESCRIPTION OF WORK ffE
I� Plumbing Code and/or Sec. of the N� "' ^' DA E� �
� •HOUSE SEWER CONNERING TO 1 J OO �/ � U �
rusuc sewec VqUDAT10N w
B.&P.Code for the 4ollowing reason ,',�,x �,� y
$EGtIC TANK SEEPAGE P1i OR � y
Dolf �ITSANO/ORDRAINfIEI� BYA� � Z
� MOtISE SEWER CONNECTING TO .
FRIVAiE OISGOSAL SYSTEM
� $ignafure __ CONNECi AD�RIONAI BLW OR � . �
OWNER-BUILDER DECLARATION wOzrc ro Hause sewee
p� OVERFLOW SEEPAGE Pli,ORAINFIEID ' '
I hereby affirm that I am exempt from the Contract�ren Exrti,cessaoa,oevweu,nuaHo�e " •
' Law for ihe following ieason(Sec�on 7037.5,8uisness and�ro- nitea aevaa oa neallooN Hovse �
l` s10n5 CoC�e�: SEWER OR D15�'OSAL SYSiEN�
i `I I,as owner of the proper�y,or my employees with wages as
�heir sole compensation,wiil do 9he work and the structure :-,i � �,•��i
i, ie nol imended or offered for sale(Section 7044,8usiness � ��.
and Professions Code). OWNER�S PBrmit 8 10 50 �s n , 7 �i
j �I,as owner of rhe property,am exdusi�ely contracting with AUTHORIZATION TOTAL FEE 2] 5Q I�
I licensed conirac�ors fo construtt�he projett(Section 7044, i HAVE Ai THIS DATE A CONiRACi WIiH THE HEREIN NAME�CONTRACTOR TO � A 6����'J
Bu5if1055 Ot1(I P�01C55iOnS CodeJ. CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO iHE Pl/BLIC SEWFR
I CONSTRUCTION LENDING AGENCY p� • �� *C�/,J�)�:'
, 1 hereby offirm ihat Ihere is a consfrucfion lending ogency SIGNEDTHIS�DAY�(.)/f� Id3 ,
. for rhe P owNex ce
� performonce of the work for which this ermif is owrvFes a�eNt � i'G G�c�5 �
�- issued(Sec.3097,Civ.C.). aooaess 31.51. AIkWAY SUIT� N CO �S'A�
lende�'s rdame TORONTO DOMINION SANK
tender'sAddress SAN FRANCISCO� CA.
� I certify ihat I have read this opplimtion and s�ats that the
� above information is correct.I agree to comply with all County �
' ordinances and Sta�e lows regalating Plum6ing and Sewars, ��
. and hereby authorize representalives of this County to anter
, �pon�he above-mentioned property for inspeUion urpose. �
`�,.._._.,.�. �. c�.., �l ��
Signoture of Permittee Dale � SEE REVERSE FOR E7(MANATORY LANGUAGE .
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