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HomeMy WebLinkAbout11_08_1984 - 21073 PATHFINDER RD - WORKERS'COMPENSATION DECLARATION � . � � . . . � � T� I hereby offirm that I hove o cariifimte of coroem to aelf - , . , . inaure,or a certifitafe of Workers'Compensallon Insuronce,or � ?��� � � � ' . °`"';`;°`1SC�„-'�9��°��`°`��tern Emp�oyers. �,�'�"e'e" . APPLICATION FOR PERMIT Policy No. m � . ❑Certified copy is hereby fumished. � . , . SEWER • SEWAGE D{SPOSAL � . . . �]�enified cpo�py is filed wah the couMy building�nspecrion COUN?Y OF LOS ANGELES BUILOING AND SAFETY ��Q C��T-2f-84APP���a�t L2e�S Pl U111b.l.tlg FOR APPLICANT TO Flll IN CONNECTION DATA . �� , CERTIfICATE OF EXEMMION FROM WORKERS' . g�iia� , � � , � � .COMVENSATION INSURANCE - � ! �u�ss � n�Tar+ .�- �. °EmH ue � (ihis section need not be comD�eted if the work involved by�he. . � ,w��E yf�ca�r+tE D� unrea . � �oautt permit is for one hundred dollars(5100)or less.) �,�ST rvv�a�a�+�cTwu '� � I i cenify tho�in�he performance of rhe work for which�hia� caosssr. Y. �++�'MFrtonn � NRE v.L ML TO P.L �' �permit is issoed,I sholl not employ ony person in ony manner '-� P.C.NO. so as to become su6jetl to�he Workeri Compensario�taws. ownca Di amond Bar Pl aza I I 3 m.vnv.r+o.. ioe ra. � O - . . M411 - . TRUNK PERMIT NO. � ROAD PEf7MiT NO. . � p�r � I pple Applitant - � . �ooRE55 - ALfID�YII WAIVER EhSEMENT RECORO.INSTR.NO. W1E Q ' NOTICE TO APPLICANT: If, aRer mnkieg thiz Cer�ificote of prr Diamond Bar Te�.no.. ' u Eaemption, yau should become su6jxt to the Worke�s' �G�� _ - � Compenwlion provisions of�be labor code,you must forrbwith oExeroriou tor rao. Hwr,ox st.xnoeNrr� �- comply wiih such provisions or rhis permit aholl 6e deemad +-„ ) rovoked. � . . � . eiocK TRA..'i � $T�IE ENQOACHNfNT � + � � LICENSED CONTRACTORS DECIARATION � N°.o��nc�s. �+it�a. � J I hereby offirm that I am licensad under provisiona of Chopter � 5�zeorioT � riowau�or . 1 9 commencin wi�h Sedion 7000 of Division 3 of Ihe Busi- �OF - - - ( 9 1 euiwincs ' au�s nns and Wofessiona Cade,and my licenu is in full force and . eff«,. ���o� Lee's plumbing CONNERiONCHARGfcFE t�cense womber 3QH��6 �ic.�Idss C36 eooaess � afiMeuRs�nir r�e Com�aciwLee'� Pl umh.inctx�e 11-8t84 o�sia�r,o. ca+ouv vr,a PROCESSED BY un rei.rio - eu ec � ❑I am exempt onder Sac. o(�he�.A.Co. ��Ns�r�o, $Q$�4G °c Ass C36 p�' � '11 I No. OESCRIVfIdVOFWORK itf Plumbing Code ond/or Sec. of the riw� j � B.$P.Code for tbe following reason � �+oUSE SEwee corirmCnr+c to � onrE r ���/ VALIDATION ' PUlLIC SEWFR ���"D j � . . SERiCTANR.SEEVKsE%TOIt FINAI y<^ / Wi5 AND/OR DRAINFIELD. _�/ ' Dafe ' HWSE SEVYER CONNECTiNG i0 BY ; � . PRIVATE DISNSAL SY57E � . Signature coNr�ci�woiiwrwi aoc.oa � . OWNER-BUILDER OECLARATION� - � � �to�s�sEv.fx � _ 1 pNF pW SEEPA�PR,pR�INFIfLD � . ' . - I hereby affirm�hot I om exempt from the Coniractor's Litense exTN.,ctssvoa,oavweu,hu.N� - � Low for the following reawn(Secton 7031.5,Buisness ond Pro• aha,q[a�w oa�Noora Nouse � � - -� /� - : feSiioni CodE�: . - � SFIMER OR DISVOSAI SYSTEM ' � �'1 5 C.�A ❑I,as owner of ihe properfy,or my employves with wages as �� �•��• • •5[� { their sole tompensa�ion,wiil do the work and the structure . � ' � � is not intended or offered for sole(Saction 70M,Businees � `� •.�� 5(j Q� . _ and Profeuions Code). OWNER'S Pe�mit f ❑I,as owner of the property,am exclosrvely ton�racting with AUTHORIZATION TaTAL FEE • • � Jr�1.��c=i ' licensed tontracto�a to mnslr�cf the p�ojact(Sectio�7044, ��.�qyE q7 THiS DATE A CONTRr1�T W1TM TIIE NERfHJ NAMED CONfRACTOR i0 p,1 � � BUSInG55 Ol1d PfOIESEiOt1b COdE�. � CONNFR THE ABOVE DESCRIBED E%ISTING DNELIING TO THE PUlLIC SF14ER. ' ' ' -" ' � �,O�,—�V�: - CONSTRUCTION IENDING AGENCY � ' � . 19 $4 , . I hereby offirm tho�there ia o consfrodton lending�agency . Sic;NEoiHiS� 8 th DAYOF NDVQ1iIb2T' � - � � , for the perfwmaace of the work for which this pe�mit is �1Of1ER� � ISSUed(SlC.3097.CiV.C.J. � W41JER5 AGfNT . . . , . ,�u 2QQ7 N. Lee Ave. So. el Monte, CA Lender's Name � - .� � Lender's Address �. .' . � . � . I certify Ihat I have read this appiimtion and stote ihat rhe � . � � � � . - _ � above informatiDn is'correct.I agree lo comply wlih oll County � � � • ' ' �. ordirwnces and Sloie laws reguloting Plombing ond Sewers, � , � � ', �-� � � - � . ond hereby outhori repre ntatives of this Covnly lo eNer . � � � upon 1he obove-m n or� rope�ry for inspedion pu�poses. . . � - � ._ . . � . . � i l'• �_'__�.. . � �;�—8-84� . � _ . . . . .. � . . '�" � Signolure af Parmi ee Da�e � � - - SEE RfVERSE FOREI(rtANATORY LANGUAGE � � � � �� .-_—'--'/'`� � " , y ' , � ���,Go Z '�� o`' %'M o $ `gf, `z� � ^ � � � • m n� qp � oq �p m � . . . _ . + o � vo m� 0A7� �� '�, '� . � � � �+� �Zm Qq O y.n �:� fi � �o ?qop P ;�; xc� � F�� � _ , n\ , o.� ��'+ . �o �cT' $ . �� cc � o o�, �.�� r ��� � N . , �• � �� ,n�q��� '° � . ,. , ` �'��� 3p "� ti $ r � `'-e } � � , O .. t � ; • ' . , � . . . .� . � �..1 � � � � � - � . • - , . � ' � � _ � - .. , ; � r � � 1 � '� ' " � � o - " ' `�� , , .. �� _ � , ��� j -- " �, ' � ��i y ' �i � ��-,��. ���" � , ' ' ��� ° � �+. �. `�, � �� � �. � .� . �� ,' ' `_, , �. , . . , � . . . . . - , . . t • , . . . , . . . . � ' � . .. . � � � . _ �, � �. ` . A \\ i ' � ' N 1 . . ' . �� i . . . . . , , ti , � S r� . � . ' � p �` � � . `� . , . � . � . �� �. . � � �, � - � N A . . � , � ' .... "� - . � . �� "' . ' , . ., . .. , , ' . �`� v _ ' ' . . . � . �1 : � ` �� �,,, � � O. • „� � ''.m Y-:v� r. � - � �.. �? � '`�� . 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