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HomeMy WebLinkAbout1140A p WORKERS'GOMPENSATION DECLARAifON ,I hereby affirm that I have a certificote of consent to self � � insure,or a certificate of Workers'Compensmion Insurance,or �h"fi^�o a certlfied copy thereof(Sec.3800,Lab C.) �-E�°fl,RE�„63� qppLlCATION FOR PERMIT Policy No. Company � ❑Certified copy is hereby furncshed. SEWER - SEWAGE DISPOSAL � �]Cerrified copy is filed with the co�my b�ilding inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY dep rtme i. Date�Applicant BRUC� L. ABTiEY FOR APPUCANT TO FILL IN CONNECTION DATA CE TIPICATE OF EXEMPTION FROM WORKERS' ewtoiuG COMPENSAT�ON INSURANCE ADDRE55 SiAiION oevTn (This section need not be completed if the wark involved by the r,nqnlNO�e tievfreFNCe uar�R permit is tor one h�ndred dollars($100)or less.) LOCAL17V IOWER I certify that in ihe performance of the work for which this eossssr GRAyD AVE. t� SUNIDSIT PIDGE DR. T�PEOFcoNNecnoN (pry�7HfROM permit is iswed,I shall not employ any person in any manner Y� Nee ai nni roPi. so as ro become subjec�to the Workers'Compensation LOWS. ��WNER P.c,No, BRAPIALEA LIMITED co inna No JOB NO d ADDRESS 3151 AIRWAY AVE. SUITE N TRUNK OERMIT NO. ROA�PERMIi NO. { Dote Appllcanf � NOiICE TO APPLICANT: If, after makin thi5 Certifico�e Of AffIOAVI� WAIVER fASEMENi RECORD INSiR.NO �ATE � •�mp�ion, you should become subje9t to the Workers' ��'iE q0 L� P' A CA �Fi No 1 8 —1��1 "pensoiion provisions af the La6or code,you must forthwith oescaianor� �or No ].� nwr oa sr wmeniHc c��nply with s�ch provisions or ihis permit shall be deemed revoked. eiocK TRACT SiqiE ENCFOACNMFNi LICENSED CONTRACTORS DECLARATION r+o oF eioc5 PER,uir No SRF OF lOT NpW ON LOT I hereby offirm that I om I�censed under provisions of Chopter ust oF SI3dGLE FAMILY RESIDENCE 9(commencing with Section 7000)of Division 3 of fhe BU51- BI1IL�INGS cHneGes ness ond Professions Code,and my license is in full force and n�� i, EffCCi. CONTRACipR �yv;u��LEA CALIF. Il`TC. CONNECTIpNCHARGEfEE LlcenseNumbe��,k��� �IC.C�o55 R ADDRF55 3151 AIRTrIAY AVE. SUITE N REIMBURSEMENiFEE COII��OCfO! BI�AMALEA CALId'yye 0 � DISTRIC7 NO. GROUP MAP PRO�ESSED BY O CITv TEl.NO — ��y BK � v C/ ❑I am exempt under Sec. of fhe LA.Co. uccNSE NU 409610 clnss B 4, N� DESCRIPiION OP WORK vEE Plumbing Code and/or Sec. of the rin�n� `) O FGUbBt C SEWER CONNECTING TO 17 OO OATE n I� ,�}�� VALIDATION w 8.8 P.Code tor ihe tollawing reason 1 � $E�iIC iANK.SEEPAGE PIT OR FINAI '�' PIiS ANO'OR DRAINFIEID �� 9 ' Do�e MOVSE SEWER CONNECTING TO BY PRIVAiE DISPOSAL SYSiEM S19ndiUlE� • CONNER AoOIiIONA�BLDG OR , OWNER-BUILDER DECLARATION ^, '/�/ORK i0 HnUSF SFWfR OVERFLOW SEEP�GE Pli.DRAINFIEID �here6y affirm that I am ezempl from the Con or's License pxTr�,CEssvpo�.oevwEu.�mnNHo�e Law for thr,follawino reoson($eCton 7O31.S,BUi5�e55 anA Pf0- ALiER,RF.P4�R OR 4BANPON Mp��SE alOnS COt�C�: SEWER OR DISPOSAt SYSTEM i J�,as owner of the property,or my employees with wages as their sole compensation,will do�he work and the struclure ..,: i 1 4.l:�i is not intended or offered for sale(Section 7044,Business and Professions Code). OWNER'S Permit $ 10 50 '{a �' a = '� Q �I,as owner of rhe property,am exdusively contratling with AUTHORIZATION TOTAL FEE 2] 5Q . licensed contractors to construct the project(Section 7�44, I HAVE AT THIS OATE A CONiRACi WITN THE NEREIN NAMED CONiRACTOR i0 � @ �C�.`�'O BUSIIIE55 011d PfOS25510I15 COd2�. CONNECt IHE A00VF.OESCRI0F0 E%ISTING DWEILING TO TNE PUBLIC SEWER .. � �-T- CONSTRUCTION LENDING AGENCY .y� T,��'�' [�� "� ����= I hereby affirm lhot there is a mnsiruction lending agency SIGNEDiH15__lG7�_—DAYOF . �C�/JG� Iv�+ v for the performance of the work for which this permit is�� owu¢a oR 4 ► !' l.Q e'"�, � � OWNERSAGENT� - i5SV2d(SeC.3097,CiV.C.�. ADDRE55 'Y ITE�N COST � A CA lender's Name TORONTO DO�INIOYd BANK �ender's Address SAIV FRANCISCO� CA. I certify thot I have read this application and state that rhe � above info�mation is corretl.I agree to comply with all County o�dinances and State laws regulatinq Plumbing and Sewers, and hereby authorize representatives of ihis Counfy to enter upon the abave-menlioned property for inspection pur oses. �,�c.a..l.JZ z S Signature of Perminee Dafe SEE REYERSE FOR EXPLANATORY LANGUAGE _ y=,�,::�..��:���; '�'. ' , .i ' ,, .:hq-t�n "Tr,,'cri. _ '�':. ;y v? :�.":�?2 '� . . . ' H;;. .a�r i .�:,],_ `, t`'� j,i, 7 ':�p. i. .. ... '.I�.J ➢�'I iADy4(. :fr ,��,.��6 • . . .., -.. . ,. . _ ^�?;j:�T^,.; ' :p.`.r': c;, :�;,�: . ' _ �?,�, �1�:r �i`c^�:,�..:<.t:�'t,r, , . -' _..i - �k�,'.'.. .. (;..1�, ": ;�,��`:`^F' T ..4;`:S,,in➢'�.' -^,S`� ,,q , � . - � *��,�r^��i?��:'H'� � � ' , iy , • . . . r'{;�_;,`.z ' :: �'11,. ..�.{ �, 'ii. . 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