HomeMy WebLinkAbout1130A (5) ' WORKERS'COMPENSATION DECLARATION
I hereby affirm �hat I hove a certificate of consent �o self
insore,or o certificme of Workers'Compensation Insurance,or �anc�zo �
a certified copy thereof(Sec.380D,lab C.) �.�e�e:���.,,�; APPLICATION FOR PERMIT � � -
Policy No. Company SEWER - SEWAGE DISPOSAL
❑Certified copy is here6y furnished. �
�Cerrified copy is fHed with the county buNd+ng inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
dep rime t.
Dare�j�'Applican�BYUCE L. ABBEY FOR APPLICANT TO flLl IN CONNECTION DATA
CE TIFICATE OF EXEMPTION FROM WORKERS' awiowc 5rnnorv oevrH
COMPENSATION INSURANCE nooR[ss 1431 S. VALEVIEW
(Th�s senion need not be completed if the work involved 6y the DIL�M�IJD BE�R � MnNHoie aeveaeNce uvv�e
permit is for one hundred dollars($100)or less.) �ocnurv �owea
� [elii{ Ihtlt in fhC elfofmonte Of}fte work for WftiCft fftis NEAGESi ♦��x� T�PEOFCONNECiION IENGTHFROM
y (� CRO55 Si. Gi\t]1VD Y CURB P.L. M.l TO P.L
permif is issued,I shail no1 emp�oy any person in ony monner
so os to bemme subject�o the Workers'Compensation Laws. owNea co unv NO �OB No
Date Appl�cani _ nooeess 3151 AIR��TAY AVE. SUITL' N TRUNKPERMIiNO ROADPEkMITNO.
NOTICE TO APPLICANT: If, of�er mOklnB thi5 Certificate Of [ITY TEL NO AFFIDAVI7 WAIVER EASEMENi RECORD INSTR NO DATE
` �pnon, yov should become subjed to the Workers' IEGAI
.pensation provisions of the Labor code,you must forthwiih oescxivnon� �OT No � Ig Hwv oe st wmerviN�
comply with such provisions or this permit shall 6e deemed
revoked. stOCK TRACi SiATE ENCROACHMFNT
tICENSED CONiRACTORS DECLARATION NO OF 8LDG5. PERNJi NO
SIZf.OFtOi NOW ON LOi
I hereby affrm Ihat I om licensad under provisions of Chopter u5F oF
9(tommencing with Section 7000)of Division 3 of Ihe Busi- sunoiN�s SINGL� F�ILY RESIDENCE cNnaces
ness and Pro4n.ssions Code,and my license is in full force and
efFect. CONTRACIOR ]j��A CALIF. INC. CONNECTION CHARGE FEE
liCCnse NUmbCr 409610 �{�,C�O55 B ApDRE55 3151 AIRWAY AVE. SUITE N REIMBURSEMENi FEE d
ca�rro�io�BItAMALEA CALI$p�e �^ ' DISiRICT NO. GROUP MAP PRGCESSEO BV �
��T�COSTA NAESA CA. iEL N 714 850-1 O1
BK PG
❑I am exempt under Sec. of the l.A.Co. iiceNse Ho 409610 �Ass $ �� �'
Q
Plumbing Code and/or Sec. of the N0. DESCRIPTION OF WORK Fee F�NA� U
�r+o�se s�weR coNNecriN�ro 1 onTe -���y/��SO VAL ATION a
Pl18LIC SEWER
8.&P.Code for ihe foliowing reason — r
SE�TI�TANK.SEEPAGE PIT OR z
PIiS AND/OR DRAINfIELD FINAL
Date HpUSE SEWER CONNECTING i0 8V
PRIVATE DISPOSAI SVSiEM
$i9�afUle�� �• CONNECT AD�ITIONAL 6lOG OR � �
OWNER-BUILDER DECLARATION woeK ro rrous�sevrex
OVERFLOW SEEPAGE Gli,�RAINFIEL�
I hereby affirm that I am exempt from the Contr s License exTrv,cessaooi,oavweu,nnaNHoie
Law for the fallowing-er.son(SECfO�7Q31.S,BUISi1C35 Ofl'�PtO� ALTER.RE A!4 OR ABAN�C4 HOUSE
'�iDt15 COde�: SEWFR OR OISPOSAI 5�'STEM
,_i I,as owner of the properly,or my employees with wages as -�� ' � '�'v n
iheir sole compensonon,will do the work and the structure �� e � � , G
is not�ntanded or offered fnr sale(Senion 7044,Business
and Piofessions Code). OWNER'S Permit __S 1 ' @ m���C
�I,as owner of the property,arn exd�s��ely comradi�g wiih AUTNORIZATION 70TAL FEE Z] Q
licensed contractors to construt�the projecl(Section 7044, i HAVE AT TMiS DAiE A CONiRACT WITH THE HEREIN NAMED CONiRACiOR i0 4 H e �_
Bu5ine55 OnCI PrOfg55i0�5 COdC�. CONNECT iNE ABOVE DESCR19ED E%ISTING DWFIIWG i0 THE PUBIIC SEWER (� /y��`
CONSTRUCTION IENDWG AGENCY T�,� ,���_ 'p O (�O C—Fi�J
I hereby affirm Ihat there is a mnsirudion lending agency SIGNEDTHIS DAYOF 4�
for ihe performance of the work for which this permit is � owr�eaoa � `L .�
issued(Sec.3097,Civ.C.J. owNERSA�ENr � �-�-��
TORONTO DOLtINION BE1NK Aooaess 1 1 Y E T
Lender's Name �
Lender'sAddress Str1N FRANCISCO, CA.
I certify ihaf I have read this appliwtion and state ihaf the
above information is correct.I agree�o comply with all County
'ordinonces and State lows regulating Plum6ing and Sewers,
and hereby authorize rep�esentatives of ihis County to enter
upon the above-meMioned properly for inspection purposes.
�....��. ���5� .
Signoture of Permittee Date 1 � SEE REVERSE FOR EXPIANATORY IANGUAGE
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