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HomeMy WebLinkAbout1139A � WORKERS'COMPENSATION DECLARATION _I hereby affirm that I have a certifimte of coasent to self - � insure,or a ceriifimre of Workers'Compensaion Insurance,or �enhazo � a certified mpy thereof($ec.3800,lob C.) «��y���v��P�� � AppLICATION FOR PERMIT Policy No. Compony � ❑Cenified copy is hereby furnished. SEWER - SEWAGE DISPOSAL .�Ce�rified copy�s Filed with the county building inspection COUNTY OF l05 ANGELES BUILDING AND SAFETY dep �Ime t. Date Applimnt BRUCE L. ABBEY FOR APPLICANY TO FILL IN CONNECTION DATA CE IFICATE Of EXEMPTION FROM WORKERS' auumN� COMPENSATION INSURANCE � nooxess 1442 S. VAL�VIEW DR. srAnoN oePrx (Thls section need not be mmpleted if the work involved by�he �aaurr DIAMOND EAP. rnnNHoie aeFeeeNce UPPER permit is or one hundred dollars($100)or less.) IOWER I cer�ify �hai �n the performance of ihe work for which ihis NEnaEsr TrceorcorrnetnoN IENG1HfROM CROSS Si. Y. CURB P L M t i0 P l. permit is issued,I sholl no1 employ any person in any manner so as to 6ecome subject ro the Workers'Compensa�lon Lpws. pWNER BRAt�.ALEA LIMITED m IMP.NO 108 ND ��� TRUNK PERMIT NO ROAD PERMIi NO Date Applicanl aooaEss NOTICE TO APPLICANT: If, o41er maltin fhi5 Certificote of ��� p�o_�ool AFfIDAVIi WANER EASFMENT RECORO INSiR NO DAiE 9 aTr COSTA MESA CA.�e�.No. o � ��ption, you should become subject lo ihe Workers' �E�A� pensation provisions of the Labor code,you must forthwith oesceivncN ioiNo. 9 HWV ORST WIDFNING �..mply with such provisions or this permi�shall be deemed rBvolfed. BIOGK 1RACT SiATF.ENCROACHMENT f�OF BlDGS PERMIT NO LICENSED CONTRACTORS DECIARATION 5¢e ov ioi rmw oN toT I hereby affirm ihot I am licensed under provisions of Chapter useor 9(commencing wi�h Section 7000)of Division 3 of the BVSi- gUIIDINGS SINGI+E' r'�$ILS.' R�SIDENCE cHnaces ness and Professions Code,and my license is in full force and CffCCt. [ONIRACIOR Bp,p,�ALEA CALIF. INC. CONNECTIONCHNRGEFEE LI[EnSeNumb@f 4096I0 �j�,��Q53 B ADDRE55 3151 AIRWAY AVE. SUITE N REIMBURSEMENiFEE � Controcror$j�j�j� !'AT TF9ate CIiY COSTA P�SA CA.*E�No �]4 850-1001 DISiRI�T N0. GROUG MAP PROCESSED BV m. �� BK PG V ❑I am exempt under Sec. of the L.A.Co. ' u ENSE NO 409610 �lA� $ Plumbing Code and/or Sec. of the N� DESCRIGTION OF WORK FEE FiNAi � � •MOUSE$EWER CONNECI�NG TO 17 00 °ATE � � VALIDATION � B.8 P.Code for ihe following reason Pl18lIG SEWER r, �� SEP71C iANK,SEEVAGE Pli OR W Daie P�15 AN��ON�RAINFIEID BY A� y -- HOUSE SE WER CONNECTING TO � Z PRIVATE DISPOSAL SYSTEM $i9nOlUle • CONNECT ND�IiIONAI BLDG OR , . OWNER-BUILDER DECLARATION woaK ro Nouse sewea 1 he�e6y affirm that I am exempt from the Comrocto' e oxe�artoEssEaooi oerw�iAMnNHote law for ihe following reason(Secton 7031.5,Buisne nf�Pr0 AtiER,REPAIR OR ABANDON HOlISE ' ;ion5 CO(�P�: SEWER OR DISPOSAI SYSTEM J I,os owner of the property,or my employees with wages as � the�r sole compensation,will do�he work and the str�cWre ,-y"� 1 ;j G j� - is not intended or offered for sale(Section 7044,8usiness and Professions Code). OWNER'S PB�mit S 1Q 5� $�e a o Q � � p �!,as owner of the property,am exclus��ely contracting with AUTHORIZA710N TOTAL FEE 27 50 li<ensed coNraUors to construct ihe project(Section 7044, i NAVE AT IHIS DATE A CONTRACT W�iH THE HfREIN NAMED CONiRACiOR TO � � �� �'`�V BUSin¢55 OnfJ PrOfCSSiOnS COC�eJ. CONMECT iHE ABOVE OESCRIBfD E%ISTING�wELIING TO iHE GUOLIC SEWER_ CONSTRUCTION LENDING AGENCY T�~ ° °e "� �:�O�'��� I hereby affirm �hat ihere is a conshuction lending agency SIGNEDTHIS z'� DAYOF �^e.�.C_.._- Iq� , � .for ihe performonce of the work for which this permit i5� - OWNER Ok ""� `�J � 1�Q 2,,,�� OWNERSAGFNI j Xti�.a� �7�_ cssued(Sec.30e7,Ci�.C.). 3151 AIRWAY AVE. N COST SA�CA. ADDRE55 Lender's Name TOR(]NTO DnMTNTpN p[{j�]IZ Lender'sAddress SAN FRANCISCO, CA. I certify}hat I hove read this application and state thal ihe � ' Iabove informofion is torrecL I agree�o mmply with all County I ordinances and Sio�e lows regula�ing Plumbing and Sewers, and hereby au�horize represenlarives of this County to emer upon 1he abo�e-mentioned p�Ope��y for inspection purpyses. � ��.. -d. 4�.�1.., to�z{�1��' , Signafure of Permittee � Da�e�— SEE REVERSE FOR EXPIANATORY LANGUAGE � ...,� .-. '��. . � ,.,"'+�'�;''' - ' ',? y 'r;. �i` .r . . . , ,�:.�:�'.,��-:�` `t',����'`+ �;�'' `"�`�'. 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