HomeMy WebLinkAbout1135A (5) � WORKERS'COMPENSATION DECLARATION
I hereby offirm that I have a certificote of consent to self
�insure,or a certificate of Workeri Compensarion Insurance,or �R^R��O �
a cerlified copy ihereof(Sec.3800,Lab C.) �����°���°��N�� APPLICATION� FOR PERMIT
Policy No. Compony �
❑Certified copy is hereby furnished. SEWER • SEWAGE DISPOSAL � ;
�Cer�ified copy is filed wirh the wunry building inspection COUNTY OF LOS ANGEIES BUILDING AidD SAFETY �--"
dep rtme t.
Dme��Applicanr RRTTCR T._ ARRRV POR APPLICANT TO FILL IN CONNEC710N DATA
' CE TIFICATE OF EXEMPTION FROM WORKERS' awioiN�
COMPENSATION INSURANCE nDDRE55 STAt�aN oEvrN
(This sec�ion need not be completed if the work involved by the i�i�rY ru�NHote ReFeRtNce UPPER
perm���s for one hundred dollors($100)or less.) l WER
I certify ihat in the performance of the work for which ihis cxossssr GREIND AVE. & SULvll'�IIL RID('iF'S D$. rvaeoFcoHrvecnoN t�NGrxFaoM
permil is issoed,1 shali not employ any person in any manner Y NRB a.i. M l To P l.
so as to become subject ro the Workers'Compensmlon Laws. pwNea BRANIALEA LIT4IT�D CO IMP NO. JOB NO
N`�'�� iRUNK PERMIi Np RDA�PERMIT NO.
�ate Applicont noouess i
NOTICE TO APPIICANT: if, af�er making �his Certificate Of [�Ty(�'�5'j'A �''S'E� iEL NO �14 850-1001 /FFIDAVIi WANER EASEMENi RECOR�IN5iR.N0. �ATE
� mption, you should 6ecome su6ject lo the Workers'
i ensa�inn rovisions of the Labor mde, ou must forthwith �E�at
.P (� Y OFS(:RIPTION LOTNO S HWY(]R51 WIOENING
co,nply wi�h such provisions or this permit shall be deemed
revoked. e�oa TRAC� 42554 S1AiE EN(;ROACHMENi
LICENSED CONTRACTORS DECLARATION No oF amcs PER^^iT No
SIZE OF lOT NO W ON LOT
I hereby affirm that I am licensed onder pravisions of Chapter use oF
9(commencing wi�h Section 7000)of�ivision 3 of the 6usi- euiioiN�s cHnaces
ness and Professions Code,and my license is in full{orce and �
effect. coNrRAc�oaBRAPfAI.EA CALIr. INC. coNNecrioN cNnacE reE
License Num6er 409610 �i�,C�O55 B AooRess� 3151 AIRWAY AVE. SUITE N REIMBl1R5EMENT FEE �
BP.AMALEA CAL �— • OISiRI�i NO GROUP MAV PROCESSED BY CI
Contracror ��e r.irv COST[� MESA CA. TELNO 714 $5 — f BK � V
❑I am exempt under Sec. of the L.A.Ca. iicenise nio 409610 class E !/� A.
PlumbingCodeand/or5ec. ofihe wo DESCRIPiIONOFWORK ffE FiNqi /
v
�P�UBLICSEWERCONNECTWGTO 17 OO DATE '�(J/�J� VqLID ION W
B.&P.Code for 1ha foliowing f2a30n $Epi�C iANK,SEECAGE PIT OR �� �
vli5 ANO/OR DkAINFIEID FINAL
Dp1e HOUSESEWERCONNERINGTO eY /iJ �
GRIVATE�ISPOSAl5Y57EM
Signoture CONNECi AD�ITIONAL BI�G OR ,R`
OWNER-BUILDER DEC�ARATION WORK TO HOUSE SEWER
1 hereby affirm that I am ezempt from the Contract ' icehse �xinF��FssvooiGORrw�RpMAivHoie
Law 4or the foliowing reason(Sectan 7031.5,Buisne and Pro- mtea,aevae oe aar.NooN t+oUSE
jiOnS COde�: SEwER OR DISVOSAL SYSTfM `� G,�t
.. 1
J I,as owner of ihe property,or my employees with wages as
their sole mmpensation,will do the work and the structure N ° ` ° ' ry t1
is not intended or offerad for sale(Section 7044,Business
and Prafess�ons Code). OWNER'S Pe�mit S 10 50 + ° °c��%n
�(I,os owner of�he proper�y,am ezdusively contrac�irtg with AVTH�RIZATI�N TOTAL FEE 2� 5� � , -
� P K�'!: (;:i
�i[ensed ConifaCfofs fo wnsiruci the project(Section��44, �ryqyE Ai iM15 DATF A COMRACT WI7H iHE HEREIN NAME�CONTRACTOR i0 �
BUSine55 and ProfesslDni Code�. CONNECi THE ABOVE DESCRIBED EXIS7ING DWELUNG i0�HE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY a 7,p�—R�
I hereby affirm thot �here is a construction lending ogency SIGNED THIS ���µ DAY OF ���C� 19� ►
for the performonce of the work for which �his permi� i5 � �NFR OR ,
OWNFRS AGENT
issued(Sec.3097,Civ.C). nooeEss 3151 AIRWAY SUITE N COSTA 'SA CA
Lender's Name TORONTO DOMINION SANIL
Lender's Address SAN FRANCISCO. C.L�.
I certify Ihat I have read this npplicarion and stote that the
above infamaiion is mrrect.I agree to comply with all Co�nly
ordinances and Sta�e lows regulatinq Plumbing and Sewers,
and hereby authorize representatives of�his County to enter
upon the above-mentioned property for inspection purposes.
`��,...,.- z�.Q�,.Q..., ��Z,� 5�--`
SignO�ure of P6rmitlee Dafe SEE REVERSE FOR EXPLANATORY LANGUAGE .
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