HomeMy WebLinkAbout1133A (5) � WORKERS'COMPENSATION DECLARATION
,1 hereby affirm that I have a ceriificate of co�senf to self
insure,or a certificate of Workers'Compensa�ion Insurante,or ib^bnZi ' '�'jI
a rertified copy ihereof(Sec.3800,tob C.) cFeoaiacv iio7i qpp�ICATION� FOR PERMIT u
Policy No. Company ^
SEWER - SEWAGE DISPOSAL `�i '
❑Cenified copy is hereby furnished. ']�% �
�]Cer�ified copy is filed wifh ihe munty building inspecr�o� COUNTY OF LOS ANGELES BUILDING AND SAFETY j�
dep rtme t.
�are���Applicani RRTTC:F T._ AFRFY FOR APPUCANT TO FILL IN CONNECTION DATA
C TIFICATE OF EXEMPiION FROM WORKERS' euuoiNG SrnnON OEPiM
COMPENSATION INSURANCE AD�RE55 145 S. VALEVIEW
(This sethon need not be compleled if the work involved by Ihe �Ocnurv DIAMOND BAR MANHOLE REFERENCE UPPER
permir is for one h�ndred dollars($100)ar less.) LOWER
I cenify rhat �n ihe performance of the work for which this �Roussi rvveoFcoNNeaioN LENGiHiROM
pe�mit is issued,I sholl no�employ any person in any manner r' �� cuRB P l. M.L.TO P.L.
so os to 6ecome subject�o the Workers'Compensation Laws. v c no
OWNkk CO IMF.NO. JOB NO
Dafe Appliconf
ADDRE55 3151 AIRWAY AVE. SUITE N TRUNK PERMIi NO. ROAo PERMIi NO
NOiICE TO APPLICANT: If, oNer mpkin ihi5 Certificote Of AFFIDAVIi WANER EASEMENi RECORD INSTR NO DATF
� �nption, you shauld bemme subje9� to 1he Workers' �TLEvq` *et y . _
?pensalion provisions of the Labor mde,you musl forthwilh cfSCRiPiioN ioTNo qwv pRSi WiDENiHG
comply with such provisions ar fhis permit sholl be deemed
revoked. eiocK TRA[i 42554 SiAiEENCROACHMEM
NO OF etOGS PfRMIT NO
LICENSED CONTRACTORS DECLARAYION sae oF�oi Now av�or
I hereby offirm thai I am licensed under provisions of Chap�er use�
9(mmmenung w�th Secno�7000)af Division 3 of the BUsi- 9WLDINGS SINGLE FAMILY RESIDENC� cHnrs�es
ness and Professions Code,and my license is in full force and
effeCl. CON7RACiORB ''�I� (�'(�.IFi'. I�T(.,'. CONNECiIONCHnRGEFEE
Ucense Number 409610 �ic.Class � AppRE55 3151 AIRWAY AVE. SUITE N ae�MeuuseMeNr fee 6„
COn1�QCfOiBRAP1ALEA CALIh301C �,rYCOSTA MESA,CA. TElN�71`'f� SSO—lOOl DiSTRiCTNO. GROU� ,NAP PROCESSEDBY y
BK P( �
❑I om exempf�nder Sec. of the LA.Co. uceNSE No 409610 cLnss $ /C ��
Plum6ing Code and/or Sec. of ihe 'y� DESCRiPTION OF WORK FEE FINAL . �"
HOUSE SEWER CONNECTING TO DATE
9 cueuc sevrea 7 00 7/��,��� VALIDA ION 6
B.8 P.Code for�he fol�owin reason___�� SEPTIC iANK.SEEiAGE Gli OR y�
GiTS ANDiOR'JRAINFIELO FINAL Z
Date HOUSE SEWER CONNECTING TO 8Y /,/
.r—�� PRIVATF.DISPOSAI SYSiF.M Lf/
SiynafUfg T CONNKT ADDIiIONAL BIDG OR ,
OWNER-BUIIDER DECIARATION wOnK to HouSe SewER
OVERN,Ow SEE�AGE Pli.ORHINfIEID
I hereby offirm thm I am exempt from rhe Contra o License exrN.,cessrooi,oevweu,MaNnoie
Law for the following reason($etton 7031.5,Bui5ne55 ond Pro- ALiER.REPAIR OR nBnNOOr+HOuSe
1i0114 COdC�, 5lWFR OR DISPOSAL SYSTEM __
J�,as owner of the property,or my employees with woges os ._�i i `�;{�i
their sole compensation,will do the work and the structure
is not intended ar offered for sale(Section 7044,Businesz ty e � r+ o } (j
and Professions Code�. OWNER'S Permit 5
�I,as owner of�he property,am exclusi�ely contracflng wirh AUTHORIZqTION 70TAL FEE j " °'��F+�
�iCensed contractors to construct ihe projecl�$CCfiOn 7�44, I HAVE AT THIS�ATE A CONiRACT WITH iHE HEREIN NAMED CONTR0.C10R i0 �`'7 C ^S
Business and Professions Code). CONNEci THE ABOVE OESCRIBED EXISTWG DwELLING 101HE PVBLIC SEWER � �' "� � `�����
CONSTRUCTION tEN�ING AGENCY T�'�' J p_ , O Z Q�"H 5
I here6y affirm ihpt there is a construction lending agency SIGNEDTHIS ��o DAYOF ���Ne 19�rJ
for ihe performonce oi the work for which this permit is o�`'NER oR ..
OWNERS AGENi
��ued(Se[.3097,CiV.C.�. ADDRE55 ��S� ATRWAV C
�ender's Nom�ORONTO DOMINION BANK
Lender's Address SE� F1�P'NC'ISC'�� CA.
I cerfify thaf I hove read this application and slate thaf the
above informalion is correct.I agree to comply with all County
ordinances and Siate laws regulaiing Plumbing and Sewers,
and hereby authorize representmives of ihis Coomy to enier
upon fhe above-mentioned properly for inspetlion p�rposes.
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