HomeMy WebLinkAboutNo Permit Number WURKERS'COMPEIVSfi710N DECL4RATION � �
I hereby affirm ihat 1 hove o cartificate of consant to salf
insure,or a ceriifica�e of Workers'Compensallon Insuronce,or �anaaxo
o certified copy therpo7f g(Set.3800,�ab�., CEBOB(REV.B/el) APPUCATION FOFt PERMIT
Policyt�DQy_v.v��—.T��°���'2�'A^�- T'...�,�,r�_�1t3T . �s
❑Ceni£ied copy is hereby f�rnished. ^ SEWER • SEWAGE DISPOSAL
�Certified copy is filed with the county b Iding inspec�fon rJ3Q� COUNTY OF LOS ANGELES BUILDING AN�SAFETY
Date e�a��sn�$6 ApplicantRCR S�7�� fOR APPLICANT TO FRL IN CONNECTION DATA
- CER7�PICATE OF EXEMPTION FROM WORKERS' euaoiNc 46�5 AYLSllt05 Place s*nnor+ oePrH
COMPENSATION INSURANCE nooREss
This seciion need no�be com leted if the work involved b the uaPea
( P Y - MANHOLE REFERENCE
permit is for one hundred dollors($10p)or less.) �ocnuTr Diauton Bar io�R
NEAREST Go 1 den J r l.n Cu TYGE OF CONNECTiON �ENGTH F2Q'A
I certify that in the performance of fhe work for which this . Caoss 5T. v. CURs P.l. M���T�P���
permit is issued,I sholl not employ any person in any manner f `
so as to became su6ject to the Workers'Compansation Lows. owNea S CO.IMP.NO. JOB NO. (O/,�C�
(,pn}e Applicant
ADDRE55 p.O• BOX J 3 2 y TRUNN PE2MIT NO. ROAD PERMIT NO.
tICE TO APPLICANT: If, after mOklnfJ ihi3 Certifita�e Of �ITy Covina ,..,�: 81ti-967-y541 AFFIDAVI7 WAIVER EASEMENT RECORD.INSTR.NO, DATE
�..emption, yau should 6ecome subjecl to the Warkers' tEGai
Compensation provisions of ihe Labor code,you must forthwith DESCRIPTION �Oi Hwv.ok si.wiDewN�
tomply with su[h provisions or ihis permif shpll be deemed
fBVOk¢(J. � BLOCK TRA STATE ENCPOACHMEM
� LICENSED CONTRACTORS DECLARATION � . F ei veennir No.
I hereby offirm ihat I am licensed under provisions of Chppfer SREOFLOT -�'NOW ON LOT
USF OF
9(commencing with Sedion 7000)of Division 3 of ihe Busi- auaowcs Residential CHARGES
ness and Professions Code,ond my license is in full force and
GffBCi. � ` CONTRACTOR • CONNEGTIpN CHARGE PEE Y
LicenseNunmber 336428 �j� CG�OS q C��V 1� M �l�7' / REIMBURSEMENTFEE Q
1�(iR L B G �J�y_�� ADDRESS
ConiraClof DOfB c„Y Rive r s i de iEl.NIX�4��7�-�0 Q 4 pISTRICT NO. GROUV MAG 7POCESSEO BY v
STATE 3642tt - ��;55 �� BK FG O
❑I am exempt onder Sec. of the L.A.Co. uceNse No. _ � G
Plumbing Code and/or Sec. of the No. DESCRIP710N OF WORK Fee FiNai �
HOUSE SEWER CONNECTING TO / DATE /� (t'/�j VALIDATION y
B.&P.Code for ihe following reason oueucsewea
SEPTIC TANK,$EEFAGE PIT OR N
� PIT$ANP%OR DRAINFIEIP FiNAI �
Oale HOUSE SEYJER GONNECiING TO BY
PftIVAiE OISPOSAL SVSTEM �
$lynature CONNECT AODITiONAI BIOG.Oft ,
OWNER-BUIIDER DECLARATION WORK i0 HOUSE SEWER
OVERFIOW$EEPAGE Pii,DRAINFIEL�
r^""'+reby offirm ihol I am exemp�from Ihe Confradar's License ex7w.,cessvOo�,oRvweu,nuNHo�e ,
�for ihe following reason(Se[ton 7031.5,BWSne55 and PIO- lLLTER.REPAIR 02 ABANDON HOUSE
tESsipnS CodeJ: SEWER OR OISPOSAL SVSiEM
❑I,os owner of ihe property,or my employees with woqes as
their sole compensation,will do the work and the strudure �
is not intended or offered for sale(Secrion 7044,Business . .:� 2 Q;(j�[�
aod Professions Code). OWNER'S Pe�miT 5 /rQ d
❑I,as owner of�he property,am exclusivey conrrocting with AUTHORIZATION TOTAI FEE � �`• m*�� � (�
licensed contractors to COI1511UC1}hE()IO�CCI�$CC110t1 7044, I HAVE Ai TMIS DATE A CONiRACT WiTH TME HEREIN NAMED CONTRACTOR TO
BUSin854 On(�PfOtC53ionS COde). CONNER THE ABOVE DESCRIBEO EXISiING DWELLING TO THE PUBLIC SEWER. � m e�r�5�
GONSTRUCTION LENDWG AGENCY �...� `„5..
I hereby affirm Ihot fhere�is a conslruction Iending agenty SIGNEDTHIS DAVOF 19_ � � + <•� j,,.;���
for �he performance of �he wark for which ihis permit is owNeaoR .
issuad(Sec.3097,Civ.C.J. owNeas n�er+r U�+.�s,�,��
ADDRE55
Lender's Nome �
Leader's Address
I certify fhat I hove reqd ihis appii[ation and Efate fhaf ihe .
above informa�ion is correct.I agree to comply wi�h all County �
ordinances pnd State laws reg�lating Plumbing and Sewers, �
and hereby authorize representatives of fhis Co�nry to enter � �
upon ihe abov -meNionad pro erry for inspection purposes. �
RuR By: C��� (�� 6/16/86
���
Signot�re of Permitiee Dale SEF RFVBRSE ROR E%PIANATORY IANGUAGF
�:�.� �. ��:-�� �������� .� -.����� � �
�. _ � �
INSPE4TORS NOTB OWNBR•HFjII:DBIT DECLAR�iTICi1�f
APPROVALS owre rimee�-.-reirs srwax�€ I hereby aNirm that I am eumpr femm the Cmtractor's
r�w r�sewEa , �;,,s, , Liceeee Law fox ihe foUowing reason(SaeNow 7D31.S,
_ Bwinau �d AvJaufuwe Cadr�Ary d4y or cwn�y
u�nG� � � mbic6+vgrins a p�riR to co�stt ahor,&�rprow.
�
r %� dneolttb,or npubr rg aprctsr�r.Prla'to i1�luwmce�
arc
�woR a�'kau�'a �� , alto reqrbac tb�appG4�t Jor sstb ponnit to flle a
QSsrooE O oxrwut❑ s:gned statrw4t ibst br 6 Hc�trd p�tF m fbr
kroui+io�s a,�tbs Cosaacl�'s Ihvwt�-/arn�Cbaptar 9
s�w'�[� srs uti
fcorrx,.enrG�g wleb saeslas 7000J of DtoLiow 3 of eb.
��� r�6�ra/+n+n m�d b��eGe/allged r�nrA�+•+'jA7+
� a r�facassc rorots ��rs�ppNcvatOe�c ch�pMuley'��t/b++sors�
. . . Ihro bn+rdr�d do!!ms It�AOA:
�F,astheoaneroEthe�peE�p�[y e¢lltdotheWr�aad
the structuec is aat intmdql m a�feeed far�ale.....
/S«�. 7044, Buism aad RoJmioas Coda�Cow
aaepur's Iwr.+ae�ri.Gom do�a soeapp�m aw omir�r oJ
propa�Dy wbo bri7dt or�proa�r fbmow.nd tnbo don
sucb worA b�rrlf A�tbYi nreb iwptour�nMtt
are nar iwem�dd or oQind jer srTi.If,bomrorr, tbs
buildieg or lerpenu�me�t 4 seld+�dt81s osr 3�of
corspbtioa, th� ourRn`ds(ldor wlfl baco tla bwd�w
. . . . M M�*8 tbae be dtd+wt BqlJd or�6Mprou.Io.tlw
. ArMa+.ojsa4.J
I�ez�pt nnder S'�c. ,
B t�P.C.for this�
Date
Uaaaer
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