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HomeMy WebLinkAbout11_8_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 � � � � �� i ,- r . I ' r rr� . . � ; �;g b4 m� � �s� z �` - . ' :J �". ! � , , � i • �T �n Dp �" v� �? f � ; '� � . . ,,,- �'O m m �j �� Z'Z" O �� , j . �a Zm OD �� OD m '� �! . ! , ' p� o� �A O �m �� � � . � ° I ___' T D 'mc� �� �9 �O A O I� _ � � . ' �Z lZ �A p O�—�y �� � .. . ' ' ' ' , � . u�i r.i0 ^p .� N � � I� , � .. _ � �❑ io ' ;. � , �f . . - • . . , , N F .,;� � . I . . i �, ❑ ' : ❑ ��I m _ . - . 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