HomeMy WebLinkAbout1217 PORTO GRANDE (16) WORKERS'COMPENSATION DECLARA710N �
I here6y affirm that I have o cen�f�caie of consen� to self
insuro,or a mrtificate o(Workars'Compenso�ion Insurance,or �edA.)D
a«.,,�,�d�o y ihereof(Sec.3800,lab C.) CE BOB I4EV.8/BI) APPUCATION FOR PERMIT
rorcy�il 1 0 Zcompany_Fireman's Fund »:
�c�,�;F;��oPY�s hereby lu.n�shed. SEWER - SEWAGE OISPOSAL
�Certi(ied coPy is iiled with rhe county bu�ld�ng insPec+�on COUN?Y OF LOS ANGELES BUILDING AND SAFETY
deporlmenl.
Do�e 8I23/83 pPp���p��RCR by:�f},Q ,�� ppR qpp���qNT TO FILL IN CONNECTION DATA
CERTIFICATE OF ExEMVTION FROM WORKERS' y�,,p�
COMPENSATION INSURANCE no�ass sr�iiov 0(PiH
(Th�s sea�on naed not be comple�ed�/the work involved by+he Nu�N��xF RE�ERFNCE �°�°
permit is Tor one hundred dollors(f100)o�less.) �aniiry D181110IId B8I i��y
nEnkESi TYif OF COnNECi'ON IENGiH FROM
I cert�fy that �n�he parfo�mance of ihe work For which rh�s cRosssT Diamond Bar Blvd Grand Ave. v, ���qB Pi Mi roPi. }
permit is issuad,I sholl nol emptoy any person in any monner p,
so as to become sub;ect lo�he Workers'Compenwtion Laws. P�����
OWhER pr sle of So. Calif. CO'MP,Fip � �pgryp O
��l TiJN[PF4MIi hp qpqp P[QM�T Np
Dale Applicanl
.00�ss 4600 Cam us Dr. a
NOTICE TO APPIICANT: I(, ofier moking fhia Certificaie of ��ry � _ �FFiDAVII x•�vta e�sf�nr RECOPD'NSIq.NO unT[ �
ERempi�on, you should become subjeU to �he Workers' iE� U
Com ansaifon ovisions of�he Labor code, ou must forrhwirh W
P P� Y oEsca�rr�txa tor r�o Hwv.pt si.w�o[Nwc v-
comply with such prov�s�ons or this pe•mit shail be daemad ��
revaked. � aio[[ LRA�7 SI�IE ENCYO4LMMEN! •
LICENSED CONiRACTORS DKIARATION w tK uocs oERMIT ND —
' I ha.e6 affirm�hat I am licensed under u�Eo�iaT �pr,�ioi
Y provisions of Ch�pier
9(co�.+menring wi�h Saction 7000)of Div�s�on 3 0(rhe Busi• �ii�s reeidential
CHARGE$
ness and Professions Code,ond my license is in full fwce ond
lfFaCl. C0�1�WACi04 b' Inc• ��YECfION CMAiG(iEF
LicenseN�mber 336428 �ic.C�oss C-36 .�coaess 12785 Ma olia Ave. wew�euascu�Nr�r
Com�ocfoRCR Plimtbing.IIIaa 8/23/83 cry RiVeislde rEi.r+o 371-5000 o�s•=�:rrao GR(YJP Mn� PPOCESSFD9Y
❑I am eaempt vnde.5ec. of�he L.A.Co. siare `'=� C-36 �V R S �� ��.�Y�Q
liCfr:SE NO Cf/155 ..�.Y.`V
Vlumb�ng Code ond/or$ec. of the � DF5CR�VfbN Of WORK R�E �Np�
MD'JSF SFWfP CONNECi'VG fJ ca�E � � � ,��( . VALIDATION
4 o�&�e s�wea p�p /
B.6 P.Code for the following reason gvi;�T�wK,S�Fo���[qT Oa Lr
v:�s nNoioc oeawwrein v:wn� ^
pate o�y�vii[DI�SP(,MAt�S�EM T� eY ✓%��^a�°'L�'
S19�OIlllP COMVFCI A(W�?�ONAL&�('i.OR , .
OWNER-BUIIDER DECLARATION M✓JRK�O MOUY SfwE4
c�aoic„n•5ternet rn.oca.vr:no �
I hereby affirm that I om e�empl from Ihe Con�rac!or's License ExiN.CESSo00l,.M+vWEif,M�NHOIE
Law for the�following reasen(Secton 7031.5,Buisness and Pro• ,airtv.4r*�a�w ox nenr.�Hp�,� ' �
fess�ons Code�: srwtk a+r.�sv�snt srs�[�+
�I,ns owner cr!he p�eFerfy,cr my emp!cyees wi!h wages as � :`b G 1.7 i�
their sole compensor�on,will do rhe work and the siruciure
is nof intended or offerad for wle(Sattion 70d4,8usiness �i � o o � � �
and Professions Code). OWNER'S Permit s ,5�7
❑�,as owner of the property,am e.clusi�ely confracring w�eh AUTHORIZATION TOTAL FEE ja I • •'J� =�
licensed conlroctors to construtt the projecl(Sec�ion 704�, �NAV[AT i4'S�RIF A CCNT�ACT WitH iM HLQE'N N4MF7 C,y`TRA(,:pR.•iJ
Businei5 ancl PrO�essions Code). CC/�xwCi T�+E nK^vF DfXai9Fp F�•51:�DwElt'tiG 10 i1�vu&�C SiWfR ,�;'v�,_T
CONSTRUCTION LENDING AGENCY '
I hereby affirm Ihot Ihere is a conslruction 10nding ogancy SIGNED TH15 DAY pF 19_ , �C.:�'—i;"
for �he performance of the work for which this permii is a^'�P�
C'NNi45 AGfNf
issued�Sec.3097,Civ.C.).
lendeis Name $Q�urity Pacific Sank A���ss
Lender'sAddress 890 N Main, SBilte Ai18� CA
I tenily i6a� I have read�his applica�ion and s�a�e thoi the
obove informa�ion is correc�.I agree to comply with all County �
ordinonces ond S!a�e laws regularing Plumbing and Sewers, .
ond hereby au!horize represen�alives of ihis County io enter
upon Ihe obove�mentioned propar�y for'nspection purposes.
R.C.R. by:�i���Gts�� ��,3 83
Signature of Permilte� Q�e ' SEE REVERSE FOII EXPIANATORY LANGUAGE
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