Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
1134A (5)
' 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 �.�<.<:-� �;. �, l,_ r�,i'^'`-=i� 'i;;ti%?'. ',R,..^' . . . - " 7n_ `:T';1�"�0� -i:.j,:A`��' •'��t� � � ... .. , _ U_; n-,� ^ .�vi t�'�_�ir ,1.�1� � . . Y'•� ,? _�,���-,,G.�.1'� "'��``� :4 . . � ! ��?:� �'.'�-°,.•.� . . �}'.�.. �..t i_ _ ,_ �t".i� ;e �� i il i.,; cti'" h �.:;. . � i A l` '.'`T` �+��1r4 z S` ��'t , !i•F'�`;.. ' � � • , • � ' ' _ 2.h• ��F,�''\� ` � ' �: �t 'i . � ~Y'. Yi :,`. 1` . �� 1� 't. �j •t . , . � ''•� �k_.. �. 1 . ' !'l � �,t� - t ,i '�'. ,t •l ,�, � ' .��...- ,, ,, ,, t 'i� 1'.,� ��t 3 `� � ' � � � . �,. . �. � ti . �' 1. 1 Y . ' , ' '.� , . �'`1 ''t` '', �'; �, ', . `` ` ' ,;� " � �''..�' `,,��::��" z.i: . `� 4�. 4 ¢�T. '� �� �'_ �', '�. �� �`�; �. r '',� '' ,` Q s�- � `'`� �', ; `t" `� f��a� , � �1 } � t p:� . . .,` [�`� 1 '`1 ', , 1' �`�.� $ . e �!;1 j 1 `1� �}� � . ` ` S �.1 + , �t' ' �. v�.. �� ��t1 �� ��'� �'�� � �'� ��� ��'� �� C���i � � � 1 ��s �� ��� 4p�� '; ,,tt ��:4 � t �`i �` �,, R� ' � . , y `' �; �.,,b�s'�` � t'44 � i, :i , i � +;I � `� '. V� M,.��-'•"':"'"",.'- ; i ��'� � � < <�;,.,.;l...,..�^� . 1 ,t � �i �1 ` � �'.} . . ' �,^,..,F . . 1 � 1 . �',tt 1l l ��, 1 . 5f�� -,�. { � 1 t � � � . , 1 � t: �1 � �'� � '�t 1 �; ; �� � ``�� , ; � . , ; 1 ''; �� �'� `� � ' � '� ,�. ' �. � ,, ,��` �1,+ �, '` �t` �.`` ' �',' .��i � .: . . � ..�, . • 1 `� •,1 ,,1 �� 't•S ' i 1 1 � `� t, ` . . l `l � ' �'', �', � , i `a .,.1 � � , . `, ;, , , 1 , , ; � i _ `1 '+ , �, ; ' � 1 , � " • - t� '�, j 't . ,` � �� � , ' , `� � 1, i � ;, ', , '! ` 'k � F 1`; • , �1 �i � +� �i- 1.. ;` `', � • � ,,;�.`: ` � j s, , , '� ; `� ; . i • ;�,;. . t' � , ' '�'� , � . . 1 ', �1 s a� � � � t : � ' �� ', �.,,`'� ``�,1 ', ,r`. �,` ��;, ,, ,,, �,,5 ; , ,`,. , ��., . � ' , �,. � ''� �`.: '� , r _ _!� , `�, °�,, � '�: , ;� S ;., . � r. 3 �'�t ,, ', +.` ,, ',1 i �, � `� . `�t ' 1 `� ,.,i � �� �;� ; �� l ' � , �'� ,' � . ``,' '�; ,. t.' �� � `t ' ' , '.. . ; `, , ` �}tl , ,` .1'', �11,, ' '' 1 , 1' t ,} '•� ' �` .,` , � � � �;' ,�� ,� ,, � :,t '� �`1 't �,1 , 'Si il ' i :� '�` '..� , � ''�. �1 `� 1 . �� ;� `','� � i i �� ,� � •. � :, ''` ; �. `� i , :�, � � , ,• .`� � , ;, 'j--. � ,t � t % `1 ,�i � ', 4 �� %` `� •. 1' ,,, '}� 1` t} ,',' ' .,_ . t ���, � 1 �, � �., S, ' '� � `;� � t , . � :.. ,'�, . ` . � j ��, ,` ...'.:... -�,t. ��t � �: j , �i� -"�,- - ± ��. �� � �'{ ..',� � ` �:��*„ : _ " <'. '� ; , � � � rv �y ...^ ^�Y Ft r � �t i 1 .i ' S:, ` �a,' �.a.y :��n __ � ' , � 1 ' �: 4� _.� n� '� �3 C. � �,~ ' - '�.'.. 'S 'd. , ; . . , . .- .�• . _i :'s":i . iv' '�'-y� ^'�. ''� ro . ;�.� , ,1 . ' .r�` '� . ' _ . �.:� '., " ,. "^ ro ::3. .1 . . . F+'a �Mj� . 'Y,:• �'` _...-., ^ d. !:� ;i:4 - _ .. � p+i . . . .e,.� ': �:y C• � � f:�' �' �. - .��l , . . . • _ ;� N"=.1. F' . ' 'T . .�i� .�� . - f�:~ � .�1- . ' . ' � .' '� � , '1".1.... _ ' H r So.r � . . . . .. - � ^' ' �'.^°j'� � � ^ "�'� ,,,. °= C/ 2"^ s a:.�-�. - - �; ' � ��; ' ry •R-' �' � ti�,,.. �`"p - - '� - '� p ��ti �p�r • . . . " � .✓, ��,, ,. '.a"; _�.r ..,.. '.�: _ . ":C. �- - _ . , 'M ,. . . , , . ��. _ ' r. *1' . . _ ^ <': G f. pd . . � . '� �: � � '$ � ' '�� - ,�'.: r�,'''`�? .�. �_ nc ' � . . � ' � , ' C '�t .. , s —"�.�-�.` - '�,.. ^ '/.r+�� . .. .1 'I c ... .. ^� .r..� � T� `�'f- = � -�:.el. " • . � ' � ' y�' � f +�N y^Y.� -�..�.� .�^'r�h � + . '�'1 ,:1 _ - r .�Y � a y S� ^/?'j _ � ., , .r -� . . . ��. , ` . _ , �^.��!Ny .+ r M V."-.�' 'e'�.. 5 C:'��.. - � -- ' � � ? ��p , . . 1 , _^:'^'.% t-. N •,�5 3� . _ • " ,� , ' .. .����q- � � �.�,� , 11' , � ���us�r/z°w�"� ..��� � , , M r ��..,,,,,...�."''...�^"'.r"'�% �„„.��' _ � � _���.,.s"'�""' �