HomeMy WebLinkAbout10237WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self I 92 000z'aPw 3ie7
insure, or a certificate of Workers' Compensation Insurance, or yw?pA4z°,
a certified co ref (Sec. 3800, Lab fE Bb8
t $s?i4� �ighland
Policy No. Company
Certified copy is hereby furnished.
Certified copy is filed with the county building InspLronW J U a i1 J ��
deparPmenP
DateL't � Applicant Bramal Pa CA, Tnr=
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the work involved by the
permit is for one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws,
Date Applicant Bramalea Ca, Inc
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
mpensation provisions of the Labor code, you must forthwith
.ply with such provisions or this permit shall be deemed
r.voked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and
effect.
License Number 409610 Lic. Class B
ContractoBramal ea Ca JnOate 1� rrji
T�—T—
❑ 1 am exempt under Sec. of the L.A. Co.
Plumbing Code and/or Sec.
of the
B. & P. Code for the following reason
�Date
Signature�yrr'���II;1ti•�_�a
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Secton 7031.5, Buisness,and Pro-
fessions Code):
I, as owner of the property, or my employees with wages as
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business
and Professions Code).
❑ I, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Section 7044,
Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued (Sec. 3097, Civ: C. ).
Toronto Dominion Bank
Lender's Name
Lender's Address San Francisco, CA
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers,
and, hereby authorize representatives of this County to enter
upon the above -mentioned property for inspection purposes.
Signature of Permittee Date
VSEWER/ a E Y "? P Ov A I
gQ*INi,Vbt.LOSES HUILDO :.., AND SAFETY
77 FOR APPUC ANT TO FILL IN
CONNECTION DATA
BUILDING
RESS 787 S. Leyland Dr.
STATION DEPTH
LITY Diamond Bar Hills
MANHOLE REFERENCE UPPER
LOWEREST
S ST.
TYPE OF CONNECTION LENGTH FROM
Y. CURB P.L. M.L.. TO P.L.
Bramalea Cd Tnc.'
P.C. NO.ER
CO. IMP. NO. JOB NO.MAIL
MAIL
ESS 3151 Airway Ste. N
TRUNK PERMIT NO.ROAD PERMIT NO.
[EID
Costa Mesa 9266850-1001
AFFIDAVIT
WAIVER
EASEMENT
RECORD. INSTR. NO.
DATEGALRIPTION
LOT NO. 12
HWY.ORST.WIDENING
K TRACT 42564
STATE ENCROACHMENT
PERMIT NO.
NO. OF BLDGS.
OF LOT NOW ON LOT
FINGS
CHARGES
TRACTOR Bramalea Ca Inc .
CONNECTION CHARGE FEE
�- ADDRESS 3151 Airway Ste. N
REIMBURSEMENT FEE
DISTRICT NO, GROUP MAP
BK
FINAL
DATE -
FINAL
BY
Pilo-
--
.
�`- CITY Costa Mesa 9264No 850-1001
STATE LIC,
LICENSE NO, 409610 CLASS B
NO.
DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER
SEPTIC TANK, SEEPAGE PIT OR
PITS AND/OR DRAINFIELD
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG. OR
WORK TO HOUSE SEWER -
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN., CESSPOOL, DRYWELL, MANHOLE
ALTER, REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
OWNER'S 'S Permit $
AUTHORIZATION TOTAL FEE 4 i SD
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
`. CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
SIGNED THIS-- DAY OF 19
OWNER OR -
OWNERS AGENTBramalea Ca. Inc.
ADDRESS 3151 Ai rwayr Ste N,Costa Mesa 9.262
SEE REVERSE FOR EXPLANATORY LANGUAGE
01