HomeMy WebLinkAbout1561AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate` of consent to, self "
insure, or a certificate of Workers' Compensation Insurance, or
76A642D - ....
d certified " y there" f (Sec. 3660 lab C.) OF eoe (REV. afar �� APPLICATION FOR PERMIT
Policy No; ompany Ste �+'UTif� his
❑ Certifi copy is ereby furnished. SEWER - SEWAGE DISPOSAL
Certified copy is filed with the county building inspection COUNTY OF LOS ANGELEE BUIL�IF1� AIJIi S:AXETY`�� �� "�� —
"" department
Date . " • AppIioant
-"CERTIEICATE``OF EXElv1`FTi�f�'1=R0%v1EkS' -
_`COMPENSATION: INSURANCE
(This section need not - be completed f the work involved by the
--'permit Is for one hundred dollars ($100) or less.)
....,:a.: ..,- .. ..
I certify that in theperformance of the- wo k�for�which this
peirnit is issued, I shall not employ any person in any manner
so cis to become subject to the Workers' Compensation Laws.
Date 6/2O/86 —Applicant T. Yreemca3].
NOTICE rTOAPPLICANT; If, after mak ng -i}• s `Certificate 'of
.d+""mption, you should become subject to the Workers'
- Tpensation provisions of the Lobar code, you must forthwith
cumply with such provisions or this permit shall be deemed
---revoked.
LICENSED'CONTRACTORS DECLARATION
I hereby off rm" that' I am`(icensed under pray sionsof Chapter
9 (commencing with Section 7000) of Division 3 of the Susi-
FEES and Professions Code, and my license is in full force and
eifed.
License Number 474887 Lc Class::L�Z4
Contractors 3"6P1P 11 Dole
❑ I am.exempt under Sec. of the L.A. Co.
- Plumbing Code and/or Sec. of the
' B. 9 P'. -Code for the following reason - -
Date
Signature - -
OWNER- BUILDER' DI:CLARAIN N - -
1 hereby affirm thatl am exempt from the Contractor's License
law for the following reason (Secton 7031.5, Buisness and Pro-
:C 'ions Code):
1, 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.sole (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).
CONSTkUCT16N' LENDING AGENCY -
hereby affirm that there isaconstuchon lending agency
for the performance of the work for which this permit is
"issued (Sec 3097, Civ. C ).
Lender's Name
Y-
a
O
V
Z
O
LU
V
d
Lender's Address
,; .,,, I cei4jfptFiot I (iavereod This pppl coiion and sr
te that the -
above information is correct. I agree to comply with all County
o}dinonces and State laws regulating Plumbing and Sewers,
- and hereby authorize representatives of this County to enter
-'Upon a abov ntioned property for inspectio purposes.
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE
FOR APPLICANT TO FILL IN
CONNECTION DATA
aUILDI SE /�.��
ADDRESS L+
STATION
DEPTH
�T�s
Locnury �i�.a.e B1iJ:L .. - - .. .
MANHOLE REFERENCE
UPPER
LOWER
NEAREST �fyt
TYPE OF CONNECTION
LENGTH FROM
CROSS ST. 7{j' a
Y. CURB
P.L. M:L TO P.l.
THE ANDEN GROUP.. _
No
JOB
OWNER
CO. IMP, NO,
NO�
MAIL
ADDRESS
TRUNK PERMIT NO.
ROAD PERMIT NO.
CITY Covina TEL NO. �j18 6 ,,,� 9541
AFFIDAVIT
'WAIVER
EASEMENT
RECORD, INSTR. NO.
DATE
LEGAL
DESCRIPTION LOT NO.
HW'. OR ST. WIDENING
STATE ENCROACHMENT
PERMIT NO.
BLOCK TRACT 35754
NO OF BUDGE
SIZE OF:0' NOW ON LOT
USE OF Single P.
CHARGES
BUILDINGS I/S�•TL��+/T}
yy^�'�'(,�T��TyRes.
T
CONTRACTOR 1`Rd'+L'1'lAN VOA ST.
CONNECTION CHARGE FEE
ADDRESS Beechwoo'd. Dr.
REIMBURSEMENTFEE
..L.82T25
CITv A.1 t+a Loma TEL. NO 71 80— 2
DISTRICT NO
I�
GROUP
MAP
9K PG
PROCESSED BY
STATE LIC
LICENSE NO 88 CLASS
l
NO,
DESCRIPTION OF WORK FEE
FINAL
DATE / / C VALIDA ON
i r
FINAL
BY f�
HOUSE SEWER CONNECTING TO
PUBLIC SEVER
SEPTIC TANK. SEEPAGE PIT OR
PITS AND TOR DRAINFIELD
HOUSE SEWER CONNECTING TO""-""
PRIVATE DISPOSAL SYSTEM
f
CONNECT ADDITIONAL'BLDG. OR - -
WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT, DRAINFIELD
►
EXTN , CESSPOOL, DRYWELL, MANHOLE
. 5 A
ALTER. REPAIR OR ABANDON HOUSE
DISPOSAL SYSTEMR'S
Permit sl0 50
ATION TOTAL FEE
r
ATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
VEE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER
V r. is : " 8 6
6 Aug
_'rpAy1 OF — ,986
OWNER OR y A
OWNEPoo
RS AGENT iA o,,VM
M { D 'a! I (T�.,�
aa C
Alta
ADDRESS 8 5 Beecihwood Li. 8 Al Lia
Oma
APPROVALS
DATE
NSPECfOR'S SIGNATURE
NEW HOUSE SEWER
CONNECT ADDMONAL
BUILDING OR WORK
rV_s_---'-•^
SEPTIC TANK, SEEP, T(S)
AND/OR DRAINFIELD
CESSPOOL [) DRYWELL
ALTER, REPAIR, SEWER OR
SEWAGE DISPOSAL SY_STEV
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
_—
BACKFILL SEPTIC TANKS Cl
SEEP, PIT(S) ❑ CESSPOOLS ❑
_
INVEICTOWS NOTES OWNER -BUILDER DECLARATION
i hereby affirm chat T mn exertipt f n= the Contractor's
License Law for'the 5D'H vving reason (Section 7031.5,
-- Business and Professions Code): Any oily or county
. ... ... . ................._..wbicb requires a permit to-toes>rxct, after. mxprOM,
. demolish, or repair,any structure, prior to its issuance,
-- - 4.ho��regair es the applicant for such permit to file a
. signed statement that be ar iice—vo! pursuas: to the
... - provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Mi--ion 3 of the
Ewsisees' aiid P>-afrssiotis Va ie) or that he is wiernpt
therefrom and the barar for the alleged exemption. Any
molaiioyx of Sectiu:i 7031.5 4 any applicon't for o p. mit
. -. subjects the apfihosxc to r ticil psna$t_p of not more than