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Home My WebLink About1128A ' WORKERS'COMPENSATION DECLARATION � I hereby offirm ihal I have a certificate of consent to self inswe,or a certificate of Worke�s'Compensation Insurance,or -anaazo � � e cert�iied copy thereof(Sec.3800,Lab C.) ��kv��R3j APPLICATION FOR PERMIT � . Po��cy No. Compony SEWER - SEWAGE DISPOSAL � �. ❑Certified copy is here6y 4umished. �]Ce�rified copy�s f�led with the county build+ng+nspection COUNTY OF LOS ANGELES BUILDING AND SAFETY de/Q tmen. Do�e y�PPlicant RRiT!'� T eu�a�,y FOR APPIICANT TO PILL IN CONNECTION DATA � CER IFICATE OF EXEMPTION FROM WORKERS' nboRess I�FZ3 S. VALEVIEW sranoN �EPT� COMPENSATION INSURANCE (Th�is sechon need nm be compieted if rhe work invoVved by the '.uN��ote aer¢rteNCE uvvea permir is£o�one hundred dollars($100)or less.) i°�Ai�IA�20ND B�R IOVJER NFAREST iVPE OF CANNECTION �{NGTH FRpM 1 ceniiy ihat in ihe periormonce of Ihe work for which thls ceo5557 t v cuxB Pi nti roFi. � permil is issued,I shall not employ any person in any manner � v c No. so as�o become su6ject to the Wo�kers'Compensation low5. oWNER Co ir,nP No. �Ge No ADDRESS 3151 AIRWAY AVE. SUITE N TRUNKPERMITNO ROAPPERMITNO. pp}y Applicont AFhIDAVII WAiVER EASEMFNT RECORD.INSiR.NO. DATE NOTICE TO APPLICANT: if, after moking ihis Certifimte of orv TEi No [ _ � +�ption, yoo should bemme subject to ihe Workers' tEGn� �pensofion provisions of�he Labor code,you must fonhwith oesr.xivnoN �oT No 1� Hwv oe sr wioer�w� coriiply wfth such provisions or ihis permit shall 6e deemed 42556 fC`/OkC[I. BIOCK TRACi SiAIF EN�ft09CHMENi NO OF BL�GS PFRMIi NO UCENSED CONTRACTORS DECLARATtON si[E;��oi �acw on ior �hereby affirm that I om liwnsed under pro�isions of Chap�er u5e of 9(cammencing with Sectian 7000)of Division 3 of the Busi- auiiow,s SINGL� FAMILY RESIDFNCE CMARGES ness and Professions Code,and my license is in full torce and cONNECnON CHaRce F[e effecl. B caNrenc�oe $ �,EA CALIF. INC �, 409610 REIMBURSFMENT fEE p. ucense Numbe� lio Class aooaess 3151 AIRTdAY AVE. SUITIs N � BRAPIALEA CALIFyote g ' oisTaicr no caouv MAP vRocesseo er V Contra[tor Uiv , TEI.N — yK GG ❑I am exempt under Sec. of the L.A.Co. uceNse rvo 409610 �<<s B F J Q1 . n;o �FSCRIPTION OF WORK fEE FiNqt {j Plumbing Code and/or Sec. of the Mpus=.sewea con�Hecriac ro oare VP1UD TION '. w� B.&P.Gode for the following reason aueuc uwee 1� �� J,j/ � S�PiIC TANK SEEGAGE OIT OR FINAI y vRSAND�C4DRA'NFI'.tO BY . 1 . . � Date HOUSE SEWER CONNECTING TO 1�,�,pr�,f � PP.NAiE o15PO5Al SYSTEM ' $i9nqlUre • �ANNErT pCpIiI�NAt BIDG OR , � OWNER-BUILDER DECLARATlON wORK To House sewea . . OVERFLOW SEEVAGE vli,ORAINiIEtD I hereby affirm that 1 om exempt from�he Cont.a or' ense ' rsin.c[asvoo��..oarwe,t.n+aroHoie - low fo�the 4ollowing reason(Seclon 7031.5,Buisness and Pro- SEwEr'7 oa oisPOsn�i 5ys�i�Nn House ;,.� .,, `�� ,� ;ian:Cadel: -- ,J.I,as owner of the property,or my employees wilh wages as .. ^ '" " � l their sole compe�sation,will do the work and the strodure is not iNended or ofFerad for sale(Section 7044,Business OWNER�S Permit S 1Q 50 � e "C�:5 U . o�d Prafessions Code). ,. . _. � �li as owner of the properry,am exclusi�e�y controning with AUTH9RIZAT►ON TOTAL PEE 27 50 <' ° "c i."�.Q ci, I censed conhac�ors to construct Ihe prolect(Section�444, i HAVE Ar iHiS DATE P�ONiRACT�'�'1ti iHE�+.FRFfN NAMED C��RACTOF TO Business and Professions CodeJ. CONNEGi ME P.BOVE DESCRIBE�EXISTING DWEILING 101HE PUBLIC SEWER (j 7.�Z"'�j 5 CONSTRUCTION LENDING A6ENCV T�—� � I hereby affirm Ihat Ihere is a construction lending agency SIGNE�TMS �� DAYOF �-UhJ�~� I � fo� the performance of the wo�k fo� whlch this ermit is � owNeu�R P OWNERS/GENT � ISSUEO�SEC.3Og�,GV.C.�. ADDRE55 315 ATRWAY AVE. N COS 'SA>CA ' �ende�'sNomeTORONTO DOMINION SANK �ende�'s/�ddress S� F12E1NCISCO� CA. � I certi4y that I have read this applico�ion and state iha�the . above information is corred.I agree to comply with all County . . ordinonres and Slote lows regulating Plumbing and Sewers, ond hereby authorize representofives of ihis CouMy to enter upon Ihe abave-mentioned prope��y for inspec��on p�rposes. � -`R � o�-��. �18-s— Signature of Permiflee �ate SEE REVERSE FOR EXPl11NATORY LIINGUAGE 3 . _.... . _.. .. . .. . ...... . . . . . . .,. . . .. , g;.,�iD��t'��.;;.�':.r�,�y,��x E :�.: � x: �� . �?�� !y� .� t J s't.-. ;'�, . : 5f_ ' r ;.�.,�:? _ . �a . . . . 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