HomeMy WebLinkAbout1245A WORKERS'COMVENSA710N DECLARATION � �
I hareby affirm ihat I hove�a certificote of consenr to self
insure,or a certificate af Workers'Campenwtion Insurance,or �6HDEY0
a certified copy thereof(Sec.3800,Lob C.) CE 808�REV.9/BI) APPLICATI4N FQR PERMIT
Policy N��.�-g�any�'�'@�^�rria�vcrzty �• -
❑Certified copy is hera6y furnished. � . SEWER - SEWAGE DISPOSAI ,
�]Ce�t�fied copy�s F�led w�th the counry buiiding inspecrion COUNTY OF LOS ANGELES BUILDING AND SAFETY
Daree������86Applicant RCR B�T:�a��Li�.� FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' euuoirvc srnnav � - oevTH
COMPENSATIONINSURANCE ADDRE55 / Ar 'tos P18
(This section need not be completed if Ihe work involved by the � rnANriOIE REFEReNce UVPEe
�o�,��rY Diamond. Bar �oWFR
permit iz for one hundred dollars(5100)or�C55.� NEAREST Golden Springs TYPEOFCONNECf10N �ENGTH FROM
I certify that in the parfarmance of ihe work for which ihis CROSS ST. Y. CORB "P.L, M.L TO P.L. '
permit is issuad,I shall nat employ any person in any manner
so os to become sub'ect to the Workers'Com ensation Lows. v.c No.
� P OWNER CO.IMP.NO. JOB NO. �
��� � TRVNK VERMIT NO, ROA�PERMIT NO. �/ �
Date Applitant aooRess P/�,O. BOX 31
��iICE TO APPIICANT: If� OffBf makin9 ff1i5 Certificate of �Ry y�Vln$ .�..*"�{� 818-967-9541 AFFI�AVIT WAIVER EASfMENT RECORD.INSTR.NO. �AiE
�mption, you should become subject to the Workers' �E�Ai
Compensation provisions of the La6or code,you must forthwith oe5ceirrioN �oT . vl Hwv.oR 5*.wioeNwc
comply with such provisions or this permit shall be deemed
feVoked. BLOCK TRA� STATE ENCROAGHMENT
LICENSED CON7RAQORS DECLARATION �, st PERMiT NO..
SIZE OF lOT O W ON LOT
I hereby affirm iha�I om licensed under provisions of Chapter use oF
9(commencing with Section 70DO)af Divisian 3 of�he Bu3i- BUILOINGS S� �. CHnkGES
ness and Professions Code,ond my license is in full force and
EHECt. /� CONTRACiOR • CONNECiION CHARGE FEE a
licenseNumber 336428 ��� C�`pSS�V�.j6 ADDRE55 � n � REIMBURSEMENTFEE v
R(:R li IN� V/1 V/O V pISiRIC7 NO GROUP MAP PROCESSED BY
CoNractor ate . arr Riverside iELNo71�F-.j�l-S�U� � 9 BK Pc Z
❑I am axempt under Sec. of the L.A.Co. ucinEise No. cinss [!7 �
NO. �ESCRIPTIONOF WORK FEE �
Plumbing Code and/or Sac. of ihe Fwa.�
MOUSE SEWER CONNECTING TO DATE y /�' ',, �
B.&P.Code for the following�eoaon � PUBIIC SEK'ER /7 ' //+ � �^' VALID TION N
SEViIC TANK,SEEPAGE PIT OR G���'� - Z
- PITS AND/OR DRAINfIELD FlNAI
��re HOUSE SEWER CONNECTING TO B� '
PRIVATE DISPOSAI SVS�EM
SIQf1a1U�E CONNECT AODITIONAL BLDG.OR ►
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFIOW SEEPAGE PIT,DRAWFIEID
r�*ereby offirm that I am ezempt from Ihe Controaor's License exTN.,ct55coot,oarweu,.xANnoie .
for the following reason(SBCtOn 7O37.S,8Ui5n255 dnd Pf0- ALiER,REPAIR OR ABANDON HOUSE �
...SiOnS COde�: SEWER OR�ISPOSAL SYSTEM ,
❑I,as owner of the properly,or my empbyees with wages as -
their sole compensation,will do the work and the structure �-� C�!.5 A
is not in�ended or offered for wle(Section 7044,Business ..
and Professions Code). OWNER'S Permit _ 8 /C C' ti a 4 � � � �
❑I,as owner of the property,am exdosively contracting wuh AUTH�RIZATION TOTAL FEE ° �
licensed coniractors to constrvct the project(Section 7044� I HAVE At THIS OA1E A CONiRACT WITH TME HEREIN NAMED CONTRAROR i0 � �� 'o �G�,�O
BU5ine55 anCl PfOfE55iOn5 CodBJ. CONNECT THE A90VE DESCRIBEO EXISiING OWELLING TO THE PUBLIC SEWER. C =
CONSTRUCTION LENDING AGENCY � � w C 7��o
I hereby affirm ihat fhere is a construcfion lend�ng qgency SIGNEDTHIS DAYOF 79— � �J�,�5��C 6
for �he performance of ihe work for which this permit is °�'°NER�
issued(Sec.3097,Civ.C.). owNezsAGeivi
ADDRE55
lender's Name
Lender's Address � �
I cerlify fhat I have read ihis application and state that the �
above informafion is correct.I agree b wmply with all County � �
ordinances and Stote laws regulating Plumbing and Sewers,
and hereby authorize represantatives of this Gounty to eMer � �
up`n�fhe�abo mentioned property for inspection purposas. .
� Y:��� 6/16/86
Signature of Permiftee Date SEE REVERSE FOR EXPIANATORY LANGUAGE
'� �' � �. +- ► . � �- 4 �a
x f + �+.
� + � 4 � , �i� * , . , .
f �x���;' � � _ I � 1����i:� � ,+ �
� � � - INSPECTqR'S NOTlS QRS���B�:��'�$.f.+L.,�x4���
�RQVA�' DATE iNsvecr€�es swr+rauac . � � � I heeeby affirm.thst I am erempt fram tha C�teactoi'a
�rv rauae sEw[t� .y�-, �++`, Licease Law far th�e [puon/SseNos 7031.9,
rd- f'
Baifuws md Anfwbsf C ANS'c{{y or cmaxey
U�6�t dlmolisb,or a��n�alAn, Nxprow,
��oRkn��o�s� eLu*a4Kirzt����t Joe'+red Arra�it�
�C3 oerwEu O xiawod:t�rwb ,h�!s linrairct p�trest!o tbe
µ . � praohieMc qf ebs Cosinocmi'4 IJcsMe Imw/C6apur 4
/mu+N+wciaS wit6 Soe/iaa yrdOQk�17Eioi�ow 3 af tb�
asm�rrwo-wo Bwiweu ard Pr�r Caq�el m'ebqt!r�6 axrerpt
ne�NoON w�1ae sew�t sb�+�+�osd sdw 8a�is Joe t6�alt�a{ p Auy
e�acrai Tuxs +�ioktioa aJSscti�70$J.S by���lh�wt�wtjw�ap�rnr�
SeEP Q Smv00�S a�ebjred tbe�i to o e�lnll of wot fnwv tban
� �.. � . . Nw bxwd�+nd douws(sf0ob:
❑I,aa the ownee of the �¢11Y do d[e wo�'•and
the structnee u not m a�aed far�aie:
/S+c 704A Bst�s mwt Cado;T7ile-Cow-
traemr4 unsss Ima alnw�o: m w o�a af
proparly urlro bwJldt or lapmwl t�,a�d+abo doa
sueb wank 6heu��! tb4t+ne6�tr
mr wos iatead�d or�for mla�Tl.6a�wvrr, tb�
bs+ld�sd o►imP��c#sold uitldw oRa y�r'o!
c+o�erklr�, tlrr m�ennbidld�r+alA bams e��Ira
oj P►uni�B tlwt bo dJd Moe btJ�d or iwp+ov�Jae tbe
. . Prrpo+•af+al..l ,
I am ei�empt�Sec. ,
B&P.C.f�tLia1 r�s�
Da�e
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INSPEC[OR'S NO� ^