HomeMy WebLinkAbout1140A (5) 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
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