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WORKERS'COMPENSA710N DECLARATION �
i hereby affirm that 1 have a ceriificate of consant fo self . �
insure,or o carfifiwie of Workers'Campensotion Insurante,or �°A6°�D
a cartified copy lhereof(Set.3800,lab C.) CE BO6(REV.e/BI) qpp��CATIC?N �OR PERMIT
PalityN�.��}.��°ny •.ty Os
❑Certified copy is hareby furnished. � SEWER - SEWAGE DISPOSAL
�Certified copy�s filed with the counry building inspection , COUNTY OF LOS ANGELES BUILDING AND SAFETY
de�a��6'%8b RCR B � /� ,
Date Applkant 3'' ��!�-�tk'�; FOR APPLICANT TO FILL IN CONNECTION OATA
CERTIFICATE OF EXEA+kPT10N FROM WORKERS' ewioiNc
GOMPENSATION INSURANCE ADDRF55 r 1 srn*i0N DePTH
(This section need not be wmpleted if fhe work involved 6y�he �p�q�iiv lliamond Bar nvNHOiE ceFeaeNce uPPER
OWER
permit is for one hundred dollars�$1�)0��E55.� ry[pRESi Golden Springs 7YFEOF CaNNECTION �ENGiH FRpM
I certify that 'n Ihe performance of the work for which this cRos55r, � v. Cuae P.�. rn.�.ioa.t.
permii is Issued,1 shall noi empfoy ony person in any manner
so as to 6acome sub'ec�ro tha Workeri Com enwtion Laws. P.c No.
I P OWNER CO.IMP.NO. l09 NO. �
�`�� TRUNK PERMIT NO. ' ROAD PENMIT NO. �
�pote Applimm aoozess P.0 Box 332
AFFIDAVIT WAI�ER EASEMENT RECORO.INSTR.NO. DATE
� TICE TO APPUCANT: If, afler making ihis Cer�ificme of �,T., � Covina ,,.,R. 818-967-9541
,.,empiion, you should become subject to ihe Wo�kers' i�Ai
Compensotion provisions of the Labor code.you must forihwith oescaivnorv �O* Hwv,oe 57.wioew�
comply wi�h such provisions or this pe�mit shall 6e deemed
reVolted. BLOCK TRA STATE ENCftOACHMENT
LICENSED CONTRACTORS DECIARATION et PERMIT NO.
I hereb af4irm that I am licensad under rovisions of Cha f!Y , SIZEOFLOT pNLOT
Y P P us�of
9(mmmencing with Section 7000)of Division 3 of the Busi- suiioiNcs Z CHARGES
�ness ond Professions Code,and my license is in full forca and p
effe[�. � CONTRACIOR .0 y�,. plt],�j 1Sl j'j(„' CONNECTIONCHARGEFEE r
LicenseNumber 33c�42� ���,�lass C—j6 d 110 18. V6. Q
RC;R—BIN/��* 6 16 Yl ADDRE � _ — REIM8l1R5EMENiiEE Q
�Of1lfdCiOf U01E . � �ISTRILT NO. GROUP MA� PROCESSEp BY V
� CITY TEL.NO.� / gK PG �
❑1 om ezempi under Sec. of ihe l.A.Co. uCenEise No. � - Cw55 (iC �
Plumbing Code and/or Sec. of the NO. DESCRICTION OF WORK FEE HNAi
HOUSESEWERCONNECTINGTp �y DAiE '� p �> VA�ID TION � d
6.&P.Cade for the following reoson PueuC SEWER � i "' � �/ � N
SEPiIC iANK,SEEPAGE PR 04 ��/J
PITS AND/OR DRAINFIEI� FINAL `���'/" � Z•
DC11B HOUSE SEWER CONNECfING TO BY
PRIVAiE DISPOSAI SVSTEM
$iyntllUlE CONNECT A�DITIONAL BIDG.�R �
OWNER-BUILDER DECLARATION WORK i0 MOUSE SEWER
i"`'��e6y affirm iha�I om exempt from the Conlractor's License ��N���E55PE��GORvwEtiA�n+NaNHo�¢ .
� �for the following reason(Secton 7031.5,Buisness and Pro- n�tea,aeNAia oR nanNooN rwus�
i255ion5 COde�: SEW[R OR DISPOSAL SYSTEM
❑I,as owner of the property,or my employees with wages as '�1 2 U,�'�
their sole compensation,will do ihe work and the struno�e },a'�,' r a � �
is not iMended or offered for sale(Seclion 7044,Business
and Prafessions Code). OH/NER�$ Pefmit S LU 5Q ,� ,. �L 7�G
❑I,as owner of ihe praperty,am exdusively contracting with AUTMORIZATION TOTAL FEE �'
licensed tonlractors�o consiruct ihe project(Section 7�44, I HAVE AT THIS DA7E A CONiRACT WITH iHE HEREIN NAME�CONiRACTOR TO w " C' (.Jr��V
BVSi�E34 qnd PIOfE5310115 COd2J. CONNECi iHE A80VE OESCRIBED EXISTING�WEILING TO TNE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY � G C.G�"'�E•
I hereby affirm that ihere is o consfruction lending agency SIGNEDTHIS DAVOF 19,_. �
for the performance of the work for which this permit is � owNea oz
OWNERS AGENT
issued(Sec.3097,Civ.C.). �
A�DRE55
Lender's Name �
Lander's Address �
I certify fhat I have reod ihis opplicofion and state ihat fhe
above information is correci.I agree to mmply with oll County
ordinances and Sta1e�aws regulaiing Plumbing ond Sewers, - .
and heraby outhorize represegntativas of�his Counly to enler -
up`nRihe�abov meNioned pr perty for inspeclion purposes.
tc y: ii�
6/16/86
G�-r�i�c�
Si9nafure of Perm�ftee Dpte SEE R6VERSE FOR E%PLANATORY LANGUAGE
��. �*t _. .� �iJt���� �•'��.�i:� ,� _•• . �� �- - �:.�
INSPECTOKS NOTES ()WNSR=�fIt�Dffii��D$CLAREI'ITOI�t
APPROYALS onre iepesaoxa swwanwF I heeebp affiroa tLas[ami esempi ftum ehe C�vacma+s
Licenee Lew far tlte 11o�!o�rpmn/S�e#ow 7(t3I.3,
Htw r�u�sew[rt Bwi+�aa wrd Profwrioesfb Cod'eh Awy dq or ooaaey
�o�� � . � ui6isA raqpim e yWrnrie to co�tpset,alter. insyro�c•
co
�r�(5)- a�k�iwi�onY tbm�����i+l�n.
sige�d ststawmet t t L�te llawrsd prrsaost W tbe
•
�cettrooi.❑ onvweu O pro�iriowr nf Nw Cmvane�orir Lg.aur liw IC6opar 4
+u +y�+ /comrwwsiyB wieb Se�n 7tl00.6 9f)Jl�au 3 oJ rbr
s
Bkti�rsu ard A�ojaakers CadtJ ar ebas bs is a�twnpt
���q abrroJrorn aid ebe 8mb far e6e aA�rd ecnsp�r.Awy
et�own s�rie rMucs Q . , rra/utba oJ3�etion 7031.3 by nwy�pAe�w�efer s�eienate
�r f] a�oots❑ � r+rbjreei tho appldcm�t to a cioll p�wsfby oJwo!�uoiv tb�
. f�w bnedr+ed dollma(iSQO%:
�1,ae tHe ow�er ot qHp�tbeee� -`and
tLe ateucta=e ig nat u�oHa'ed�'oqk..
/Sec. 7Pi4,S�m a�d FigfiafaRs Coda 7`tn Cor
.. tractor'k L.4�e�re Isw don+rot to ms a�us�r of
psop�rey ru(ro bwild�ar knproao t�mo�,wd�o daer
ancb uorA h&rae�f ptotdd�d tbae srcb nwprowm�ad
_ an wot Intuded ar o$ee�ilor a�k.�Lntoawr,tb�
buitdi�g ar�ee�i 4�� oss y�m'oj
comjiletFor. tbt owWrJal�dw wlA baw tbs b�d�w
, ol P+�B tbat be dfd�ot brJ1d or he�pivar jor tl»
Arrpo�e of aalwl
. - . � � I e�elCmjK'tt�fi$�. �
� .. � $�P.�.'-f01'�S T�96R
Date
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IFRPECTORS NQTEB ,_..
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