HomeMy WebLinkAbout1259A WORKfR3'COMPENSkTION DEClARA710N � n
I hereby affirm that I have a certificate of consen� to self II
insure,or a certifiwte of Workers'Compensalion Insuronce,or. 76A64z� ZS
o certified mp II1@lCOI SBC.C�BOO,LaS C.� � CE BOB(REV.B/81) qpp�,�CAT14N FOR PERMIT
Poi;�,,it�86�213$�mpan�Fremont Indemnity �, �+
❑Ce�t�f�ad copy is hereby fumished. � SEWGR - SEWaGE DISPOSAL �
�Cerfified copy is filed with the counry ilding in pe � 530/,3Q COUNTY OF LOS ANGELES BUILpING'AND SAFETY
depariment. �1
�a�e 7/�.7��pmpplimnt (�sl2� FOR APPLICANT TO FIIL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION fROM WORKERS' ew�oiNc �/ p,.," srnnor+ � aearH
COMPENSATION INSURANCE ADDRE55 ry'-7 u r? G � G
(This section need no�be completed if the work involved by the Diamond Bar r^"NHoiE aEFERErxE owea
� permit is for one hondred dollars($100)or less.) iocnutt
I certif �hot in 1he erformance of ihe work for whith this �uEARE57 Golden S rin s Car 10 rvaeOFCONNecrioN �,uGiHFeorn
Y P CRO55 ST. P g P• V. CURB P.L M,l.TO P.l. �
permit is issued,I shall not employ any person in any manner
so as to become su6�ec�ro the Workan'�Com ensation Lows. v.c No.
� P OWNER � CO,IMP.NO. JOB NO. D I
� '��� TRUNKGfRMITNO. ROADVERMITNO.
Date Applicant noouess
/"�TICE TO AGP�ICANT: If,"after mpkifl IhiS CBflifiCO�@ Of - '��� AFFIDAVIi WAIVER EASEMENT RECORD.INSiR,NO. DATE
s �,T� Covina �"TE;.No: 67-9541
mption, yoo shoold become subjecl lo the Workers' IEGAI
Compensation provisions of�he labor code,yoo must forthwi�h DESCRIPIION io* o.� HWY.OR ST.WIDENING
comply with such provisions or Ihis permit shall be deemed
re�oked, e'.ocK TRA SiATE ENCROPCHMENT
� LICENSED CONTRACTORS DECLARATION - ra oF e��cs Peemir No.
SiZEOF LOT NOW ON LOT
1 hereby affirm tbat I am licensed under provisions of Chapter use or
9(commencing with Section 70D0}of Division 3 of iha Busi- eunoiN�s � cNnec�s
ness and Protassions�Code,and my license is in full force and
effect. coNrenaoR R.C.R. Plumbing� zIIC. CONNEC110N CHARGE FEE �.
License Number ��r,�z,�_Lia Class�_ dp�Il0 18 V2. �
NDDRESS b REIMOURSEMENT FEE Q
COnIfaC�C�R PT.TTMRTNC_ Date��31`85 . PISTRICTNO. GROUP MAP PROCESSEDBY V
CITY TEL.NO. � BK PG � Z
51ATE UC. `D O
❑I am exempt under Sec. of the LA.Co. uceNse No. cwss
H
Plumbing Code and/or Sec. of ihe No. DESCRI I N O W RK Fee fiNai �
HOUSE SEWER CONNECfING TO //y �_ DATE /� � r� �yqL�pqTION �
6.8 P.-Code for Ihe fol lowing reason vueuc sev�s [ r.
SEVTIC iANK,SEEPAGE PIT OR FINAL a
PITS AND!OR DRAINFIELD
Dale NOUSE SEWER CONNECTING TO BY
PNIVATE DISVOSAL SYSTEM
$19nO1Ufe CONNECT A�DITIONAL BLW.OR �
OWNER-BUILDER DECLARATION woRK ro House sewea
OVERFIOW SEEPAGE PIT,ORAINFIELO
��reby affirm ihat 1 am exempt from the Coniratlor's license exrN.,[essPoa,okvweu,onaNMoiE .
for the following reason(SeCtOfl�O3I.S,BUISlIC55 pf1CI Pf0- ARER,REVAIR OR ABANOON HOUSE
. .lOnS COdeJ: SEWER OF DISYOSAL 51'SiEM , L, n
:.'�_� 2 J.�%/'1
❑I,as owner af ihe property,or my employees with woges as
their sole compensation,will do the work and the siructure $;�o c o m � [�
is not intended or offered for sale(Section 7044,Business
and Professions Code). OWNER�S PErmit E Q � , ���:
❑I,as owner of�he property,om exclusively contracting with AUTHdRIZATION �'�TAL FEE '� Q
licensed mmracfors to consiruci the project(Section 7044, i HAv�Ar rnis onre a coNtencT wrtH 1He Herter�Nnmeo mNrancroa to � - - "���,r'�l.i�
8u5ine53 and Professions Code�. CONNEGi iHE A60YE DESCRIBED E%ISTING OWELLING TO THE PUBIIC SEWER.
j�a.
CONSTRUCTION LENDING AGENCY � � � O E`. �.�C
I here6y affirm that there is a conslruction lending.agency SIGNED7HI5 - PAYOF 19_
for the performance of the work for which this permit is OWNER OR
OWNERS AGENT
issued(Sec.3097,Civ.C.J. �
ADDFE55
Lender's Name �
lender's Address
I certify that I have read Ihis applimtion ond state �ha'the -
above information is wrrecl.I agree to comply with oll County
ordinantes and$fate lows regulafing Plumbing and Sewars, �
and hereby oothorize representatives of this Counry to enter �
upon the p6o e-mentioned property for inspection purposes.
RCR BY;��q.,�,�� 7/31/86
Signafure of Permitfee Date SEE REVERSE FOR BX?LANATORY LANGUAGE
� ' ` � � �� �1� `f` + ��`y � �
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�'�`'�r 6
� - "� �.� ' - _+,a�.� _ _
i� i�rav�troR's porEs OQVNBR BT3II:13B1t'DBCbARt3�1'If�N
APPROVALfi oare ��rorrs sxsw�+u� I heeeby aHirm thnt F am e�oempt ftom t6a Contnetar's
I �w Hous�sEvha 1�� � . License Isw for the foIIawtng rnwn(S�eNow 70#1.9.
Tsrueness aid Aajefriows Codr�h Asy city or coasty
��� wbicb►eqaiws a paridt to coM+p'aae,altar,Jrrprow,
rFrai sffr,v�h i ds�bJq or rekqh mty aars�w,prior m#s i�saaa.
�atarhir�rmo aLo nqrins tha 4pylJmsi j�o�srcb prner/t w fJls s
r�snoa❑ ortrweu D siartw�st�1:liot!is h lteussd p�t to tbe
pro�6ioxs�tba Carhactar++Licsntr Lqw/G'baPar 9
���� 1���+r8 wieh S.cNos 7Q�(U�Dlotttoa 3 oj rb.
Bxciaas mid P�oJsaim�t�adRt or ebW ba it asonrpt
�ea�+�e�as s tbe�+fi'un+aKd tbr 6ws&ja'tbe rAg�d ox 6�ow•A+ry'
�7� nia7rtios oJSretfa.T03i.5&y��y�lk�i a permrt
s�. D �sr Rts❑ mbj�c4 t8�appHa�t m a e�ctt of+at+wore tbqw
fJw bxr�sd dollart/fSQOA:
�I,�tGe oweer drhr vI[tdatllewofk-and
ehe avuceau�e ir not as�[d toe
/Sac. 7044�Bnd�as r�d Codar�a:aa
a.emek rla,w Lmw euss wos yy�{y m aw waa..aI
prvperty mbo brifdt or Gsp�nvrs tLnvos.asd'min don
� surL�+oor6�fi�arlj �A6qt�tfrcb i�#
are�ot btn�dnd ar Jor rpk. �bo�: tbr
bnrldMB m`�mprowmn�t#mld�au.Ww'oj
comR4tias, tl� m�qrnb�Jldirr+t�l lpor tba B�e,nder
. � oJ Prociy tbra be did woi brild or l�row Jdc elw
purpur.of aa4.1
�Sm e�IIpt wpode�'Se�. >
H&P.C.for tLls reaxo�-
_._ Date
Oavfler
INSPECTOR'S HGTES ' . .