HomeMy WebLinkAbout1139A (5) � 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
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