HomeMy WebLinkAbout1249A � WORKERS'COMPENSATION OKLARATION ' �
I hereby offirm ihat I have a certificate of consent �o self
insure,or a certificote of Workers'Compensation Insurance,or ]6AC42D
o certified copy thpreaf(Set.3800,Lab C.) =Ee°B�RE�.e,B�� . qppLICATION FOR PERMIT
Policy N�,6����°ny 'ty �s
�[�Certifiad-copy�S ne�ebY+��n�snea. SEWER • SEWAGE DISPOSAL .
�Certifled copy is filed w�rh�he cou�ry bu'1di�g i�spection rJ30�`� COUNTY OF LOS ANGELES BUILDING AND SAPETY
de�o�m16�86 RCR B ., �`�j�:�;
oare Appliconr^. y� FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' eunowc 'tp la STATION oerrH
COMPENSATION INSURANCE � nooaess
(This section need no�6e comple�ed if the work involved by ihe pl•dII�Ond. B•dr ' MqNHOIE RffERENCE oy�R
permit is for one hundred dollors($100)or lass.) �O[nuir
I certi4y�thar in the performance of the work for which this ROSSSSi. TVPEOFCONNECTION �NcrnraoM
Golden Y. CURB PL Ml iOP.I.
permir is issued,I ahall not employ any person in ony manner . P� Na I /^
so os ro become s�6jec1 fo ihe Workers'Compansation Laws. owNea co.iMa.No. �oa No. /���J p
'�"A�� TRIJNK PERMIT NO. ROA�PERMR NO.
�pte- Appliconl aooaess P..O, oX- 332
AFFI�AVIi WANER EASEMENi RKOR�.INSTR,NO. OATE
. TICE TO APPLICANT: If, ofrer moking this Certificate of �,T,. � Covina � 818-967-9541
..emption, you �should bacome su6ject lo the Workers' �E�Ai ",.,,.,�
Compensation provisions o4�he tabor code,you must ior�hwith oescaivraN �or � HWY.OR 5T.WIOENING
comply wiih such provlsions or Ihis permil shall be deemed
IBVOkeC1. ' . BLOCK TR T STATE ENCROACHMENT
� LICENSfD CONTRACTORS DECLARA710N �& � PERMiTNo.
size oF�oT � ' oN�o*
I hereby affirm that I om licensed under provisions of Chapter u5e oF a�
9(commencing wiih Section 7000)of Division 3 of ihe BUSL BUIIDINGS [HARGES
ness and Prafessions Code,and my license is in full force and
BffeCi. � ' � COMRACTOR CONNECTION CMARGE FEE y.
LicenseNumber 336428 �ic.Class C'36 qpORESS ' � - REIMBURSEMENTFEE Q
RC R PLLTMS IN�'e 6�1 6/Y�6 �ISTRICT NO. GROUP MAP PROCESSEO BY V
CaNraCfor arv Riverside ,E�.�114-371-5000 Z
S1AiE LIG. �� BK PG O
❑I am exempt under Sac. of the L.A.Co. uceNs�No. cv�ss C—36
Plumbing Code and/or Sec. of the Np- DESCRIPTION OF WORK F� FiNAt �
HOlJSE SEWER CpNNECTING TO DATE �/ VALIDATION L
B.&P.Code for the following reason Puauc sewex f !�' �� h
SEPTiC TANK,SEEPAGE PIT OR ..���'J �
� GITS AND�OR DRAINFIELD FINAI /'" "''� /
Dafe Vqll$E SEWER CONNECTING TO gY LKl�J!
VRIVATE DISVJSAL SYSTEM F�
Signature GpNNECi ApDITIONAL BI�G.OR �
OWNER-BUILDER DECLARATION � woaK io HouSE SEWea
f�`^��eby affirm thaf I am exempt from the Contractoi s License zrNF��ess EPoaGoev+fJ°RAMnivHo�
�for ihe following reason(SCC�00�O$I.S,BUISlIE95 O�d Pro- ALiER,REPAIR OR ABANDIXJ HWSE /I
ItS410rIS Code�: SEWER OR DISPOSAL SYSTEM � � (�4.�A
❑I,os owner of fhe properly,or my employees with wages as �:.� o e s � �j
iheir sole compensation,will do ihe work and ihe siruct�re �
is not intended or offered tar sale(Section 7044,8usiness � ,�,.m G�,5 C
and Professions Code�. OWNER�S Pe�mit a J� � .
`- , ��c„_r
❑I,as owner of the property,am exclusively comractin9 with AUTHORIZATION TOTAL FEE ,la7 , ,, �;
litensad con�ractors�o consiruct ihe proje[t(Section 7044, i HAYE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
Bu9inC55 af1CI PfOf25SiOf19 COdC�. CONNECi iHF ABOVE pESCRIEE�EXISTING OWEIIING t0 THE PUBLIC SEWER, t�(�.'��a.��
CONSTRUCTION IENDING AGENCY �
I hereby affirm fhot ihere is a Conslru[fiOn lending agency SiGNEDTHi$ DAYOF 19_
for ihe performance of the work tor which this permit is OWNER OR
issued(See 3097,Civ.C.). owNensnceNT
ADDRE55
Lender's Nama
Lendar's Add�ess
I certify that I hava reod this applimtion and stafe Ihat ihe
above information is mrrect.I agree ro tomply with oll County �
ordinances and State lows reguloting Plumbing ond Sewers,
and heraby aothorize represenlotives of Ihis Counfy to enter � . �
u��nRtheBaboyp-menti�ro�fy for inspection purposes.
x y11 6/16/86
� �
Signature of PermiRee Dafe SEE REV@R56 FOR EXPIANATpRY LANGUAGE
� ` `+ � a r ° � . � �� ~'� �� � , .��� �► `# ' '"��
. '
� , `�� ' ti _' �_� -��i _ �•� _ �- -_ �- - -
. INSPECTdR'8 NCT� 0�]�$R B�JII.DBR DEC�.lYRAT'ION
APPROVALS wTe iwrscmes s�r+Axwe I hmbp afHem tbat I em e�mpt from the Cmtrxtor't
�w�sEvxa Liceaee Lsw for the fMbwing rdem fSeeHow 70j1.5�
� Bwinw wrd Pv�rsriowr Codrh Awy dty o�cowray
w
oir+�o�w�SeR� w6icD r+4�r a pn+�to mn�6srk dhr,iiwp►w».
� .dinrdisb,or rrpal awy sb�rek:ef.Pr1br io lb Lvw�co.
scar�t s�r.r�(s�
u�art�oa�n�ert�o dm ngriro eb��t for areb�ean�&to JWa a
assrooi❑ oevwEu D sigrrrd srafmaat Ea it=�t�wd y�rrarare m tM
Ara�+doa*�tbs ConhQcpw�S Ifrnrq Iow(Cbqptor 9
�w�i�t�s�ii s°Rra, —. f�ci�8 w;tb Ser&as 1Q0019I DrodrioR 3 oj rlro
Brcea�eu aed Prg/i�iosr Cads�m rbae be ts assmpe
�vwtt� tbqrfros awd fb�i�mJt jor tb�dt�q�d AMy
��ncmrnta oin/d�►olSsc#uw7031.Sbya�y�Wart�t�aa�iper�nit
g[e: ❑ mwoois❑ srbjscA tbr�pdfcose w a chil pnwlOy of wot nwre tbaw
, l�w brrda+nd doJGas/.f3�J.:
�1,�tt�owner otehe e[�It�ehaeei�"'�d
the stractare u�mt' ot a�od�or ad�
fSa. 7044,Hwisea mid Co�n T6s Carr
srac7�i I�r l�nu daa wnt�aa oemsR ol
pno�+nb�v bwdds or nnjnoua atdw6o dors
meb wari l�neej(pmo/d�d tbai arb lrwpeouiawsa
wa+we intesdwd m�m&Ior mle..�;bowoar, eh�
bs�ildfwg ar�t is rold�awr yra'of
coc�pl�tioa. t6r au�anbd�dir�l lisar fb�lwrariw
ofp►�e�q t6ui M did+wt 6rifd w iarproor Jee ebe
t+��M+�l
I s�a e�mpc nnder 5�r. ,
B�r F.C.fm this r�rm
Date
mm�nr
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