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1134A
' WORKERS'COMPENSATION DECIARATION _I hereby offirm ihat I have o certificafe of consen� to self , � insure,or a certifimte of Workers'Compensmion Insurance,or �y^Eti�� a certified copy ihereof(Sec.3800,Lab C.) ��E b�y-�E�,�8;; qpp��CAT14N FOR PERMIT Policy No. Company � ❑Certified�oPY�s hereby furnished. SEWER - SEWAGE DISPOSAL G �Ce�r'rfied mpy is flled with the county building mspeWon COUNTY OF LOS ANGELES BUILDING AND$AFETY dep rtme Dare���Applicaml;RUCE L. �1BBEY FOR APPLICANT TO FILL IN CONNECTION DATA CE TIFICATE OF EXEMPTION PROM WORKERS' awmwc WMPENSATION INSURANCE ADDRE55 L�F6O S. VALEVIEW DR. staTiON DEvrn (This seclion need not be mmpleted if ihe work involved by�he �p�Aun D�T�ND B�' ^^^NHaE REFERENCE u�vEa permit is for one hundred dollars($100)or less.) �owea I certify thot in the performance of�he work for whith Ihis cRosssi C'�ND AVE. & SUMMIT RIDGE DR. t�PEOFCONNECTION �NGir7FROrn permir is issued,I shall not employ any person in any manner `' cuza a i M.�.ro v t. so as�o become subject to ihe Workeri Compensa�ion Laws. P,c.No oww�z P�RLIMALEA LIMITED co i,�nP No ,oe No '�`�'�� TNUNK PERMIT NO. ROAD PERMIi NO. Date Appl�cant ADDRESS Y A E SUITE N 9 CIiY COSTA MPSSA� C AFFIDAVI7 WAIVER EASEMENT RECORo INSTR NO DAiE NOTICE TO APPLICANT: If, af�er makin this Certificate of Aiti.No�714'� 350-1001 � mption, you should become subject �o ihe Workers' �E�Ai � 'lpensalion provisions of ihe La6or code,you must forthwith DEscaivnoN loi No nwv,OR Si wioeNinG , comply with such provisions or Ihis permi�sholl be deemad revoked. auxK iRACi 42554 S1HiE ENCR09CHMENT - LICENSED�ONTRAQORS DECIARATION rao or emcs PERMIi NO SIZE Oh LOI NOW ON LOT � I hareby affirm that I am licensed under provisions of Chapter u5e oF 9(commencing with Section 7000)of Division 3 of fhe Busi- gNtDMGS - ID I�TCE cHap�Es ness and Professions Code,and my license is in full force and @F{CCt. �ONiRACTOR BRAMALEA CALTF. INC. GONNFCTIONCNARGEfEE liCCnSC NVmber�1n�{,yyyy_LiC.CIo55 ADDRESS REIMBURSEMENi FEE � Co11trOClorBP.AMALEA CALIFDare �—_ CITV COSTA MESA,CA. .E�No (714) 850-1001 DISTRI�TNO GROUP MAV PRpCE55EDBY o ❑�am exempt under Sec. of the l.A.Co. Sinre uc �6 eK � �tJ UCENSE NO CLA55 � Plumbing Code and/or Sec. of tha �O �ESCRIPTION OF WORK �E riNAL o •HOUSE SEWER CONNECiING i0 DAiE •y VALIDA ON �j PUBLIC SEWER W B.8 P.Code for the following fCO3Dn $�GiIC TANK SEiPAGE Pli OR FINAI � r����� � Da�e_ GITS ANDiOR DRAINFIElO gY y — HOUSE SEWER CONNECTING iD � PRIVATE�ISPOSAI SYSTEM � $i9r1a1UIE CONNECTAODITIOMAIBI�G OR ► OWNER-BUILDER DECIARATION WORK TO HOUSE SFWER OVERfLOW SEEPkGE Pli,ORAMFIEL� I herehy affirm fhot i om exempt from the Canfracfor's Licen 2 E%TN.,CESSPpOI,ORYWELL,MANHOLE law for tha follow�ng reason(SP.CIOn 7031.5,BUiSnP.55 OnCI Pf - oliEN.REFqiP OR A9AN�ON HOUS' . $iOnS COC�C�: SEWER OR DISPOSAI SYSTEM ��,as owner of fhe property,or my employees with wages as � -. ; �j �,�� F, iheir sole wmpensation,will do ihe work ond ihe struc�ure is nat intended or offered for sale(Section 7044,Businass H a y n a 1 !) ond Professions Code). OWNER'S Permit g �I,as owner of the property,om exduswely com.ading with AUTHQRIZATION TOTAI FEE � � "�� 7��� licensed contrac�ors to conslruct ihe projec�(Section��44, I HAVE Ai iH15 DATE A CONiRACi WIiH THE HEREIN NAMEO CONTRACiOR i0 BUSI0055 OIICI P�OTCSSi0115 COCJ2�. CONNECT THE ABOVE�ESCRIBEp E%IStING�WELLING TO THE PUBtIC SEWEk " �- -[ /:;��<' CONSTRUCTION LENDING AGENCY -r�4... Q _ I hereby affirm thof Ihere is a constru[lion lend�ng agency SIGNED THIS Z� DAY OF�,y,2t� I W ► �7.�l L�b J� for the performance of the work for which this permit is owNexoa --p 4�... � /—�` ISSVBd'S2C.3097�CIK C.�. OWNERSP.GENi �j�_ �b 1 tender's Name TORONTO DOMINION BANK nooaess�1 S7 ATRWAY A�TF._ N (:OS A .SA_ A tender's Address SAN FRANCISCO� CA. ' I certify ihaf I have read fhis application and state thot the Ii� above informatian is mrrect I agree to comply with all Counry ;, ordinances and S�a�e laws reguloting Plumbing and 5ewers, j}' and hereby authorize represeniaiives of this Coun�y to en�er (:. upon the above-mentioned property for inspection purposes. ! ��._._.. � . �IZc�L�.s--- I��. $ignofure of Permiffee Dote �— SEE REVERSE POR E%PLANA70RY LANGUAGE �,:<;-.�� �, - ;„t l", r o i`�:r`�� '.'z rti:?'. ',R�.^' . . . - " 7n_ `:T';1�"�0� -i:,j,:A`��' •'��?� � � ... .. , _`U_t „�,� " .y�tn'�_�r ,1.�t� � . . x.��� ,, ',���-,G�<.1i� "'�A`:•,':4 . . � �1 '�i:! -'.t"°,.•.� . . �},.�.. ",�t i_ - ,_ .:iy� ;� _ ;`�. I ., c� � h t.:�. . . . • i;A l� ;`T� ^��`�r4 z S` ��'t , !'c��1' . , , � � . , � ' � . ¢.h` �z'�''\� ` � ' �: ��t 'i � . . ' ~Y`. i _':�i ��� k �t`1� � 't. 'j ,t . . � . �. '�'` � {. 1 !�� �\ ,t ,,�•� � i ,'j" ii ;� ��,� ,, % � . . ��Y~�; �� � ,i`^ ,`i �. � �i ;. `� .� �i• 1. 1 i �. 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