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1128A (5)
' WORKERS'COMPENSATION DECLARATION � I hereby offirm ihal I have a certificate of consent to self insu�e,or a certificate of Worke�s'Compensation Insurance,or 'a�nazo � � o cert�iied copy thereof(Sec.3800,Lab C.) �������kv��R3j APPLICATION FOR PERMIT � . Policy No. Compony SEWER - SEWAGE DISPOSAL � �. ❑Certified copy is here6y 4urnished. �Ce�rified copy�s filed with the county building+nspection COUNTY OF LOS ANGELES BUILDING AND SAFETY de/Q tmen. Da�e y�PPlicant Ruiir� 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 uvo¢¢ (Th�is sec�ion need nm be compieted if the work InvoVved by the i«Ai�i�20� $� '.uN��ote a[r¢rteNCE towea .. permir is£or one hundred dollars($100)or less.) NFAR�sT rvrE oFwNNEaioN �N�rH rRon+ 1 certiiy ihai in ihe periormonce of Ihe work for which thls ceo5557 1 v cuxB Pi nti ioFi. � permi�is issued,I shall not employ any person in any manner � v c No. so as l0 6ecome tu6ject to the Workers'Compenzation low5. oWNER CO irnP No. �Ge No ADDRESS 3151 AIRWAY AVE. SUITE N TRUNKPERMITNO ROADPERMITNO. Date Applicont AFhIDAVII WAiVER EASEMENT RECORD.INSiR.NO. DATE NOTICF TO APPUCANT: if, after moking ihis Certifimte of orv TEi No _ � +�ption, yoo sho�ld bemme subject to ihe Workers' tEGn� �penso�ion provisions of�he Labor code,you must fonhwith oesr.xivnoN ioT No 1� Hwv oe sr wioer�w� comply with such provisions or ihis permit shall he deemed 42556 fCVOked. BIOIX TRACi SiAIF FN�ft09CHMENi NO OF BL�GS PFRMIi NO UCENSED CONTRACTORS DECLARATtON sizEc��oi Ncw on ior I hereby affirm that I om liwnsed under pro�isions of Chap�er u5e of 9(mmmencing with Sectian 7000)of Division 3 of the Busi- auiiow,s SINGL� FAMILY RESIDFNCE CMARGES ness and Prefessions Code,and my license is in full torce and cONr+ECnON CHakce F[e effecl. B mNrenaoe $ �,EA CALIF. INC �, 409610 REIMBURSFMENT fEE p. ucense Numbe� lio Class aooaess 3151 AIRTdAY AVE. SUITE N � BRAPIALEA CALIFpote 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. iceNse rvo 409610 ciqss $ f J 'Q1 n;o �FSCRIPnON OF WORK fEE FiNqt {j Plumbing Code and/or Sec. of the 'quse sewea conwecnvc�o DPTE YPILID TION '. w� B.&P.Code for the following reason aueuc uwee 1� 0� ��J,j/ � SiGiIC TANK SEEGAGE GIT OR FINAI y vRSAND�C4DRA'NFI'.LO BY . 1 . . � Date HOUSE SEWER CONNECTING TO �Kpw(,f � PP.NAiE o15PO5Al SYSTEM ' $19np1Ure • CCNhEr`qCCIiICNAt BIDG OR , � OWNER-BUILDER DECLARATlON wORK To House sewea . . OVERFLOW SEEPAGE Pli,ORAINiIEtD t he+eby offirm rhat 1 om exempt from�he Cont.a or' ense ' vsrr:.cessvoo��..oarwe,t.MaNvoie � law fo�the 4ollowing reason(Seclon 7031.5,Buisness and Pro- StwEr'7 oa oisPOsn�i 5ys�i�Nn House ;,.� ., `�� ,� ;ians Cade2: -- ,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 Codei. ,. . _. � �li as owner of the properry,am exclusi�e�y controning with AUTHARIZAT►ON TOTAL PEE 27 50 <' a "c i J Q c'i, I censed conhac�ors to construct Ihe prolect(Section�444, �HAVE A�1Hi5 DATE F�ONiRACi W1ty iHE NFRFiN NAMEO CCN��RACTOF TO Business and Professions Code�. CONNEGi ME PBOVE DESCRIBE�EXISTING DWEILMG 101HE PUBLIC SEWER (j 7.�2"'�j 5 CONSTRUCTION LENDING A6ENCV Tr� � I hereby affirm Ihat Ihere is a consirucrion lending agency SIGNE�TMS �� DAYOF �-UN�� I � fo� the performance of the wo�k fo� whlch this ermit is � owNeu�R P OwNER>/GENT � ISSUEO�SEC.3Og�,GV.C.�. ADDRE55 315 ATRWAY AVE. N COS 'SA>CA �ende�'s NameTORONTO DOMINION SANK � lender'sAddress S� FRANCISCO, CL�. � I certi4y that I have read this applico�ion and state iha�the . above information is wrred.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 t k � "_'" ...."°�.f'.Z;'�'.'��GC'�', 'y ;9 ... °.".S...n .F.� . '. `S� r''�l!�. 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