HomeMy WebLinkAbout1243A WORKER9'COMPENSAiION DECLARATIOIV �
I here6y offirm that I have a certificate of consant to self �
insure,or a certificata of Workari ComPenwtion Insurance,or iaaeo2o
PolcyfN���`��`���o��°'r`e�.o�t Indemnity �3�B�REV.B/el) qpp�ICATION FOR PERMIT .
�Certified�oPY is hareby furnished. �SEWER • SEWAGE DISPOSAL �
Ce�rfied co is f�led with rhe counry b ilding inspec�ion � COUNTY OF La5 AN4ELE5 BUILDING AND SAFETY
de6yF�fi4r��b RCR By:
Date npplicanr QJ FOR APPLICANT TO FILI IN CONNECTIQN DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' eui�oiN�
COMPENSATION INSURANCE nooaess STATION oerTH
(This section need not be completed if the work imolved 6y the �p�AIITY D�a.T[IOTSd Bar M4NXOLEREFERENCE UPFER
permit is for one hundred dollars(5100)or less.) �ov+ER
NFAREST TYPE OF CONNECTION IENGTH FROM
I certify that in �he performance of�he wa�k for which ihis �Ras55,.� Golden .S T'111 S � v. cuae P.�, m.�.roP.i.
, permit is issued,I shall not employ any person in any manner
so as to berome wbject ro the Workers'Compensation Laws. ' v.c No.
OWNER Cq.IMP.NO, JOB N0. O
��� TRUNK PERMIT NO. RDAD PERMIi Np,
Date Applitant � nooaess
. 710E 70 APPLICANT: If, afrer making this Certificate of cirv COV1T11 � Tci..tio.
518-967-9541 AFFIOAVIT WANER EASEMENT RECORD INSTR.NO D.>1E
.mption, yo� should become subjec� to the WO/kBfS� . LEGAI � �
Compensation provisions of the Labor cade,you must forihwith o�.sceivrioN tor Hwv,ok st,wioeNiNc
comply with such provisions or ihis permit shall be deemed
revoked, BLOCK iR 7
STATE ENCRDACHMENT
PERMIT NO,
UCENSED CONTRACTORS DECLARATION 5¢eoF�or ' ow oN ior�
I hereby affirm�hat I om licensad under provislons of Chapter use oF
9(commenting with Section 7000)of Division 3 af ihe Busi- euimiNcs CHARGES
ness and Rofessions Code,and my license is in/f�ull force and
effecr. 3 36(E 2 t5 W-,�6 CONTRACiOR CONNECTION CHARGE fEE �
License N v�rn�.rv r�n 4ic C s 1
d
�z�v .����-� �. A��RF55 REIMBURSEMENTFEE O
Conirpctor � Date CiTY Riverside � TE�.No714-371-5000 �ISTRICTNO, GROUP MAP 7ROCESSE�BY V
�T 9K PG O
� I am exempt under Sec. of the LA.Co. iictnise No. ctnss `�
�. DESC IPTIqNOF WORK cEE
Plumbing Code and/or Sec. of the F�N,yi V
HOUSE SEVr41t WNNECTING 70 �AiE
8.8 P.Code for the following reason � Pueuc sev.�a — �� 9 ��v VALIDATION N
. SEPTIC TANK,SEfGAGE PIT OR � �
Dp�e PITS AND/OR DRAINFIEL� gNA� �
HOUSE SEWER CONNKTING i0
PRIyAiE DISOOSA�SVSTEM
S19fIO�UIB CONNECf ADDITIONAI BIDG.OR - �
� OWNER-BUILDERDECLARATION woaKroHousesev,�a ,
�ereby affirm fha�I am exempt from the Conkactor's License �xrNF��Essvooi oRvwEiRAunNHae -
for�he following reason(Secton 7031.5,Buisness and Pro- nireq,qepqie oR asallooN Nouse �
..a5iOn5 COCIC�: SM'ER OR OISPOSAL SYSTEM
❑I,as owner of the properiy,or my employees with wages as
iheir sole compensation,will do ihe work pnd the sirutture �
is not intended or offered for sale(Section 7044,B�siness
and Professions Code). QWI�ER'S � Permit � �� ��
❑I,as owner of the property,am ezdusively contracting with AUTHORIZATION TOTAL FE� 7 �i ✓`� �Q,��
licensed coniractors to consfrutf the project(Section�044, �HAVE Ai THI$pATE A CONTRACT WIiH THE HEREIN NAMEp CONi-ACTOR TO
BUSi�@5g Q�(f P/OI25510f15 COCIC�. CONNECT iHE A&OVE DESCRIBEO E%ISiING�WELLING TO TNE PUBItC SEWER. p��,.c+ e • � C
CONSTRUCTION LEN�ING AGENCY
I hereby afFirm that lhere is a construclion lending agenry SIGNEDTHIS DAYOF IG�
for the erformance of the work for which this �'NEROR t c^ S�r�
p permit i5 owNERSAGENT ' G "�J
issued(Sec.3097,Civ.C.). - . �
, ADDRE55 k c� �h�I��_
Lender's Name '-' '
Lender's Address ��=C��`�6
I cer�ify ihat I have reod this application and state 1ha1 Ihe �
above informaYion is correc�.I agree ta tomply with all CouMy � �
ordinonces and State laws regulatinq Plumbing and Sewars, � �
and heraby pufhorize representativas of this County fo en�ar � � � �
��onthB�oy�-m�`�ioned�p'`rope+�inspec{i9ry_pyr�qses.
_� 4� n vllo� v
�-��� ��
Signoture of Permittee Do�e SfE REVERSE FOR EXPIANATORY lAN6UAGE
� — f � � ����_�'� y� �"�� �� -
�_ naretra�rs�s OWlHER BF31LD��DEGLARx9E1 TOI�i
APPROYALS oare �r�rors swr+� i hereby effirm thnt 1 em ampe fram tl�Cmmactot's
raw House sewEp
Liceaee Law fw the�rason/SKaf�7031.Y.
�i � ' Bnsisqs mwd Aq/nstiaa !+dsy d� or corwa,y
wbic��r�gritsr s prr�it m msr#aef,afNr, bsprmie.
� desnolYsb�or neparr oxy sk+crdtn.lerra►to its iaaowcss,
a��miaTrt'�ox�� � dro rrqwra t8s°PpGc�tt fo►arcb J�a►rsit to f110 a
cesroa❑ oawv�xi p +iBr�d atc�e�rws tLsi!N&llna��d pw�e to eIw
. A+�4f�+CoatracMrS I�an�ss Lina l��ar 9
s�i�l�on� (ro�wne+�ciwg witb Sre�los 7QQ0}oj DiaGias 3 oj tde
orscc�+r�cr n.uo�wo Badseu ard Pmf�dast Cnde/or tbaf l»ia e�sa�npt
�vwao�+ �ewa tb�and tM bm/s Jor ib��/J�d esrm�.Auy
� Q T�sroaa❑ +�io7eeiori�Sktias 70�1.� a�nelc
ssbj.ea sDPpcuw f��t r+non tbmr
Cw b�ndnd doJlma fi3Q0/.:
❑�,u the owner�the �elll do t6e sao��'-and
the sWrnue ir n0t i ol'a�eced ia°aRl�.,
/Src. 7044.Br�ard Codr:Ttw Cow.
dace�or4 L�crsrs Lam doa wosapp dy to aw awMer of
properey w(w bidldr ar k�pinna tl�irro�.m�d wLn dow
sreb u�ark �S[d/P�V�d tlt6i a�ttk�nO
me rot�tNrd�d or�/fj�k+'rofc.�f,baranmm� tbe
brlldl�or lsipmwnrpi#mld wdtEdi►oee Y�'�
c�axpJrAior, tbe otuwo.b�dddrr u1lA Lmcr tGe dmndar
� . . �F�+iB�t ba dld+Ktt 8�idd ar iutprnne,{ar tlw
pwip�•9f ml�.l ; '
� I am ezempt�der Sea .
B&P.C.for tLis e�on
. . Aate
f)wner
nrsvtcrorrs�s _