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WORKERS'COMPENSATION DECLARATION
I hereby affirm ihat I have a certifica�e of consent to self •�
insure,or a tertifimte of Workers'Compensation Insurance,or �n^R^Zn
� a cerr�fied copy thereof(Sec.3800,lab C.) �-rK,��,REv„83� APPLICATION FOR PERMIT
Policy No. Company �
� ❑Certified copy is hereby fiumished, SEWER - SEWAGE DISPOSAL � -
1 �Certrfied mpy is£iled with the co�n�y building i�specnon COUNTY OF LOS ANGELES BUIIDING AND SAFETY
dep tme
� Date����Applicant BRUCE L. ABBEY FOR APPLICANT TO FILL IN CONNECTION DATA
� CE IFICATE OF EXEMPTION FROM WORKERS' euimiNc
� COMPENSATION INSURANCE nooacss 1427 s. vaLEvzEw nx. sTnrioN oevrN
! This secfion naed not be mm leted if Ihe work involved b ihe uvvea
� � P Y LOCALITY M4NHOlE REfERfNCE LOWER
permi�is for one hundred dollors($100)or less.)
I cer�if �hot m Ihe erformonce of ihe work for which this NEnaesi fYPEOFCONNECT�ON iENcrnFkon4
v a caoss sr GRAND AVE. & SUNIMIT RIDGE DR. r. cuae c i M.L.TO P L
permit is issued,I shail nor employ ony person in any manner r c.rvo
� so as to become sub�ect to Ihe Workers'Compensption Lawa owNek $�j.TAj,$A j,IT'fi'j$D m imv No ioe No
��� TRUNK PERMIi NO ROAO ffRMli NO
� Date Applimm nooeEss 1 j ' Y
NOTICE TO APPLICANT: If, afier moking this Certifi<ate of �iTy C�ST�1 i"�SA�CE1��Nd�14� 850-1001 AFF�oawr wnivee enseMeNT aecoao wsTx No DAiE
� � +nption, you should 6emme subject �o the Workers' iE�q�
� ipensation provisions of rhe La6or mde,you must forthwith oescaivnoN toi No. 1$ nwv oa s*w�oeNwc
� cumply with such provisions or this permit shall be deemed G.2556
re�oked. aia'K iFACT STATPENCROACHMENi
NO OF Nl�GS PERMIT NO
UCENSED CONTRACTORS DECLARATION s¢e oF ioi NOW ON LOi
� I hareby affirm thot I om licensed under provisions of Chapter ust or
9(comme�dng"�.ith Sed+o��000)of Divlsion 3 of+he Busi- BUILOINGS SINGLE F�ILY RESIDENCE cHnRces
ness and Protessions Cade,and my license is in tull force ond
CffE[�. CONiRAC1 CONNECiION CHARGEfEE
l�cense Number 11(�9�'1�(� LiC.C�ass qDDRE55 3151 AIRWAY AVE. SUITE N REIMBURSEMEM fEE �
Conxacto�'�T�'EA CALIFpo}e crtv COSTA h1`ESA,CA. ,E,Na.(714) 850-1001 oisreicrno. cuouv rouc wtOCE55ED8Y o
BK Ga �
STA�E LIC �
❑I om ezempr under Sec. o the L.A.Ca uceNse rvo aass �
NO �ESCRIPTION OF WORK FEE
Plumbing Code and/ar Sec. of the _ piNqi JJJ ) . Q
9 P08LSCSEWER�NNECTINGiO 17 — oo �ATE �/�y/�ff VALlDAT N W
8.8 P.Code for�he fallawin reason � j o
SEPTIC iANN.SEEPAGE PR DR FINAL � y
PIiS AN��OR ORAINFIELD �
Dqte HOIISE SEWER CONNECiING TO BY
PRIVATE OISPpSAI SVSiEM
Si9�O}��Q . CONNECT AD��TIDNAlBLOG OR ►
OWNER-BUIlDER DECLARATION —� woaK ro House sewea
OVERFLOW SEEPAC,E P17.�RAINFIELO
� I hereby affirm that I am exempt from the ConiraU s Ucense exrN.,cEssvocx,ourweu,maN�aoie
p LOW IOf tMP.fOIIOWi�(�fP,(ISOfI($P.C7(J�]�37.$,BUiSlIESC 011d PIQ- ALiER,REPqIR OR ABAkD(iN HOUSF
� 510n5 COdC): SEWER OR�ISPOSAI 5�'STEM
'=1 � �A
��.
� .J i,as owner of the proper�y,or my r,mployees with woges as ''
their sola compensation,will do the work ond the strudure fi' • v � a 7 C
� is not intended or offered for sale(Section 7044,Business permiT E L� ,5�
�ry and Professions Code). OWNER'S � @ ���v�
Lry.I,as owner of the property,am exclusively comracting wfth AUTH�RIZATI�N TOTAL FEE `2] $�
litensed conirac�ors to conslruct ihe project(Section��44, I HAVE AT THIS DAIE A CONiRACi WIiH THE HERFIN NAMED CONiRACTOR TO B ^ 9(7.�i�G
Bu5inC55 OnCJ PIOfC55iOn5 CO(IeJ. CONNECI iHE ABOVE�ESCRIBE�EXISi1NG�wEIIING TO TME PUBIIC SEwFR
CONSTRUCTION IENDING AGENCY ► �'�,���—�� � �
I hereby affirm thal ihere is a consirucfion lending agenry SIGNEDTHIS DAYOF 19_
fOr tI10 OWNFR OR
performance of the work for which this permii is owrveesnceni
issued�Sec.3097,Civ.C.). aooaess 3151 AIRWAY SUIT� N COSTA MESA,CA '
Iender's Name TORONTO DOMINION BANK
Lender'sAddress SAN FRANCISCO� CA. �
I certify that I hnve read this opplication and state tha�the
o6ove information is correct.I agree io comply with all County
ordinances and S�ate laws regulming Plumbing and Sewers, .
and hereby a�thorize representatives of ihis County to enter
upon the above-mentioned property for inspection purpos s. , .
� �..�..._. �- e
I Signofure of Vermittee ate SEE REVERSE fOR EXPIANATORY LANGUAGE
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