HomeMy WebLinkAbout1137A (5) ! � WORKERS'COMPENSATION DECLARATION
I .i hereby affirm that I have a certificote of consent to self �
M1 insure,or a certificate of Workeri Compensarion Insurance,or �n.u+zn
` a certified copy thereof(Sec.3800,Lab C.) �F�^%:��°.,,d}, APPLICATION��FOR PERMlT
+ Policy No. __Company
❑Ceriified�oPY is here6y furnished. SEWER • SEWAGE DISPOSAL � �
�Cerrified copy is filed with the county building inspecNon C�UNTY Of LOS ANGELES BUILDING AND SAFETY
dep fine t.
�me�Applim��BRIICE L, ABBEY FOR APPIICANT TO flLl IN CONNECTION DATA
CE IFICATE OF EXEMPTION FROM WORKERS' euimwo SiAiION oecrr�
� COMPENSATION INSURANCE nooaess 1450 S. VALEVIE[d DR.
(ihis sechon need not be wmple�ed if fhe work involved by the nMNHOiE REFERENCE VPPER
permit is for one hvndred dollars(SI00)or less.) �aAUT�DIL�MOND BL� irnyEa
NFP.RCST iYPE OF CONNECTION LENGTN GROM
I ce�tify that in the performance of the work for which ihis ceosss GRAND AVE. & SUMNIT RIDGE DR. Y. aRe Pt M�ioP,�.
permit is issued,I shall not employ any person in any manner v.c rvo.
E so as to become su6�ect to ihe Workers'Compensa�ion LawS. OWNEk BRAMALEA LIPTIT�D m vae No ioe No
� aooaess 3151 AIRGIAY AVE. SUITE N — TRUNKGENMI7N0 ROAUPERMITNO
Oale Applimnt
NOTICE TO APP�ICANT: If, ofrer mOkin �fti5 Ceftiflcafe Of AFFIDAYIi WAIVER EASFMENT RECORO,INSTR NO DAfE
9 cnv TEL NO
'' �ption, you should become sobjecr ro �he Workers' �E�Ai
� pensotion provisions of the labor code,you must forthwith oe5camrioN toi No ] Hwv ox sr wmeNinC
comply with such provis�ons or ihis permit shall be deemed
revoked. eiocK TRACT 42554 STATE ENCROACHMEN7
LICENSED CONTRACTORS DECLARATION No oF etocs r�xmir vo
SIZE OF L01 NOW ON lOi
I hereby affirm eha�i om licensed under provisions of Chap�er use or
9(commenNng with Sec�ion 700p)of Division 3 of Ihe Busi- , auaoiN�s SINGLE F� Y ESID VC cHne�es
ness and ProfPssions Code,and my license is in f�ll force and
e}feCt. �- CONTRACTOR CONNERION CHARGE FEE
License Number 409610 LiC.CItl55 $ . � ADDRESS Y kEiMBl1RSEMENi fEE �
Conrracto� BRLIMALEA CALI�'bte aTv GOS1A P1ESA�CA, reiNo (�14) 8$�-1�01 o'S'RicTra, �eoua �tnnv Pcocesseoev �
` eK PG
❑I om exempt under Sec. of the LA.Co. �: iicenis�No anss B l�� �
NO DESCRIVTION OF WORK FEE
Plumbing Code and/or Sec. of the FiNAi �
•HO'JSE SEWER CONNfCTING i0 DArE i yALIDATION
B.8 P.Code for the following reason PUBIIC SEWER "���.���� �V
� V
SEPTIC TANK$EEPAGE ili OR fINAI �
vli5 AND/OR�RpWFIElO q
i Da�e VqU5E5EWERCONNECTINGTO BY /�/ ',�
i PRIVAiE�ISPOSAL SYSTEM
! Signoture N^�� CONNECT ADDIiIONAL BLDG OR ► w
UWNER-B1111.DER DECLARATION woRK To Noust sewea
.T/ERRIOW SFEPAGE PIT.DRAINFIEID
� I hereby offirm that I om exempi from the Co rac � License E%iN.,CESSPOOL DRYWELL MANHOIE
� Law for Ihe Eollowing reasor 5ecton 7031.5,9 ' ess and Pro- o,itea.Qera�R oe nennooN Nouse
'.i0113 COdE�: SFWER OR OISVOSAL SYS�EM =+1 �; ;)r%�
� �I,os owner of rhe prope�ty,or my employees with wages as f• s o u � (j
� their sole mmpensa�ion,will do ihe work and the shuUure
is not intended ar offered for sale(Seclion 7044,8usiness + 9 6�'l.�,.Q
andProfessionsCode). OWNER�S Permit S 1� 5�
(�I,as owner oi the property,am exclusively connact�ng with AUTHORITATION TOTAL FEE 27 $0 a � ._ ..;';;�
licensed contraUors to construcf�he prolect(Section�044, i HAVC Ai iH�S OAiE A CONiRACi WIiH THE HEREIN NAMED CONTRACT(JR TO • � ' /
BUSInESi anCJ PfOfB5510n5 Co(�C�. CONryECT THE ABOVE DESCRIBE�EXISTING OwEUING i0 iNE PIIBIIC SEWER Q 7,`;.��"�h
CONSTRUCTION LENDING AGENCY � 'C�� \JN�_ ,
I hereby ofFirm that there is a consiruction lending agenty - SiGNEDTHIS 7{n " DAYOF � t9�
fOf fll2 ' OWNEROR . 1 !�
performonce of ihe work for which this permit IS ; pWNERSAGEM_�µae�...— 7�f- i
issued(Sec.3097,C�v.C.). nooeess3151 AIRWAY SUITE N CQST SA,CA.
�ender's Name TOROIVTO DOMINION BANK
lender's Address SAN FRANCiSCO, CA.
� I tertify thot I hove read this applimlion and stafe that fhe
above informalion is correU.I ogree ro comply with all County
� ordinontes and State lows regulating Plumbinq ond Sewers,
pnd hereby aulhorize represenlotives of fhis Coumy to enter
upon Ihe above-mentioned property for inspecfion purposes.
� Signot�re of Permiftee SEE REVERSE FOR EXPLANA70RY IANGUAGE
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