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HomeMy WebLinkAbout10_29_1984 - 21073 PATHFINDER RD (4) i WORKERS'COMPENSATION DECLARATION � � . I here6y affirm �hat I hove a certificate of consent to self � � � ❑ inswe,or a certificote of Workers'Compenwtioa Insurance,or 76A6d10 � • � �fl P i;`�� `�'�'�`��a°9;�`est`e�n Empl oyep� "B09`"`",`°" qppLICATION FOR PERMIT ° ❑Cer�ified copy is hmeby furnished. � � . SEWER - SEWAGE DISPOSAL . � � �((Certified copy is filed w�rh�he counry building��.�cno� , CCUNTY OF LOS ANGELES ' BUILDING AND SAfETY departmenr. � � . . .. . oo�e 10-2q=R4 n�i�co�� I ee's Pl umfii n� FOR APPLICANT TO FILL IN CONNECTION DATA � CER7IFICATE OF EXEMPTION�FROM WORKERS' � � - COMDENSATION INSURANCE . ���ss Z� . P h f� � suiqr+ avrH� �� - (ih�s aecr�on need na be compieted if the work involved by rbe ' ipuutv Di.amond &ar N�AN�KKE REffREniCE � ul � q permit is for one hundred dollars(f100)or less.) . - I�certiiy ihoi'n��he periormance of�he work for whicfi�his � �rtos55T. �. �� n'rcor[oiw�[twN ttr�TM Fua� Y.� Nffi P.L M.L.TDY.I. permit is issued,I shall not employ ony person in ony manner p� / so os io become sobject to the Wwkers'Compensa�ion Lawa. p�y�R � m.v.w.r�q. � oo�� n�u�a�r �'�SS 21073 Pathfinder TRUN1(PERMITNO. ROADPERMITNO. NOTICE TO APPIICANT: If, of�er moking this Certificare of ��n. Diamond Bar,E�.�. . . ������� WAIYER EFSFMENT RECORD.INSTR.NO. �A7E _ Exemplion, you should betome svbjecl-to the Worke�i �i � Compensmion prov�sions of�he lo6or code,you must forihwi�h oescaimioni iot rao.� r�w�.,pe St.uno�Nir� . comply with such provisions or this permit sholl be deemed �/ '(�.—J�7 . revoked. ' ' � � BtoCx iRA�7 /�(. /T�l ( ` STATE ENCFOACHN{NT '� UCENSED CONTRACTORS OECIARATION � ���&D�� °�Q �� ' I beroby affirm Ihat I-am licensed under provisions of Cliapter � 5iztortot rqwoni toi �/��J � -. 9(commen�ing wirh Seaion 7000)oi Divlsion 3 of the Buei• e�uiio�s comnerci.al . a,,,�s neu and Profassions Code,ond my license Is in full force ond , ef{G[i. CONTRAROR 1 ' CONNECiION CHARGE FfE licenseNumber 30.8146 �.� ��ass C36 �ooccu 24Q7 N. Lee Ave. Rf�^^�,�NT�f d � co�„o�,o, Lee's Plumbirt�,e 1Q-29-84 . �,,,: So. El MonteTE,,,�_ 818 444-0528 DISTNICiNO. GROW BK �,P� PROCESSEDBY � : � ❑I am exempt under Sac. of the L.A.Co. iICENS[np, �tt�n55 � n' Plumbing Code and/or See. � of the . ^�. DESCRIVfION OF wORK FEE FiNP.I �•� ���, O. wOUSE SEWER CONNFCTING TO DAi[ p VALIDATION �I' � PU&K SEWER B.&P.Code for 1ha following reason � ori T�.NK,$EFi11GE FIT 0R /� �� � YITS AN�/pR pR1111�F�ELD F�N�� � �9 5�2 8 A� . ��� + � Dote r+ovs�s�w[a coru�[cnrac to °Y . L. %liYAlED15105A15Y51EM #� ���.�'� O 1 Signotoie . . . . . . [o�w�ecr aoortrowx emc.oa I OWNER•BUIIDER DEQARATION H'�K TD HWSE SfWER - QJERfIOW SEEPAGE VIT,ONAINFiEID S � •,�2 7.5 O I hereby offirm�that I om exempt from the Contracror's license EXTN.,CESShOOI,ORYWEIL.MANMOIE � law for the following reason(Setlon 7031.5�BUISfIC55 OOd Pf0• AITER,REPAIR OR AMNDpN 1qU5E � � � ����,� � fesstons Code): scwee oe oivosu srsr�M 2 7.5 0 �Q I,os owner of rhe property,or my employees�witb wages os I��.O H-B Ll �heir sole compenwlion,wiil do the work ond fhe strocfure � _ -. is nor intended or oHered for wle(Section 7M,,Business ! and Professioas Code). ' OWNER'S Permit S i ❑I,os owner of the property,am exclusively cont�ading wiih AI�THORIZATION TOTAL FEE —Q Ncensed confroctors to consli�d ihe projett($ettion�0�� �NAVE AT TMIS OATE A CONiRAC7 WI1H iME HEREIN NAMED CONTWNCTOR TO Bua�ness o�d Professions Code). ca+�a TH[neove ocxa�eEo exisnr+c oweiur+e to r�oveuc sewea. ' ._i CONSTRUCTION IENDING AGENCY � - �� 1 hereby affirm ihat fhare is a mnslroction lending ogenty S�GNEDTHIS DAYOF 19� � ; for the performance of the work for which this permit Is ' ��R� �� � ,,,� u� � i issoed(Sec.3097,Civ.C.). - � a`�'MEQs�cer+r . , . Lenderi Nama ' �Eu2-4O��- PP Ava_ So_ Fl Mnn .�a; CA lender's Addross I tertify that I have read ihis oppliwtion and s�ate fhat the � � � obove informotion is corratl.I agree�o comply with all Counly ordinonces and Sfate laws regu�ating Plambirg ond Sewen, � � �� � and heroby avthorize representalives of�his Counry to antar �� • upon N obove-mentioned property for inspection purposes. � � - - . �r`a}� �.C.�+! S� 1{L-'JQ-$a- � nature of Perminee Dofe � � SEE REYERSE FOR EX►IANATORV LANGUAGE ti ) i _ __ _ --- -------- --- -- - _ - --- - ---- � , ------ - . _, � .. . .-. . . . ... __ . _ . . . � r � . ... y . . .,. � . . . , , .. ' _ ' - � ' .. i . . .�. . . 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