HomeMy WebLinkAbout1261A WORKERS'COMPENSATION DECLARATION ' � � � �
I heroby affirm that I have a ce�tificate of consent to self
insore,or o certi4icafe of Warkers'Compensatian InSV�anCe,O� - IbA6a4D �
a�e�„��o�a���ec.�38�,�ab C.) �E B�,REv.B,e„ qpp��CATION FOR PERMIT
voi��Y mpony remont Indemnity �.
❑Certifiad copy is hereby fumished. SEWER • $EWAGE DISP�SAL �
�Certiflad capy is fued wirh the munty uilding inspe 'on 530/ COUNTY OF l05 ANGElES BUILDING AND SAFETY
depar�menl. �.
Dote ��r�/,�4Bpplicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' aui�owc
COMPENSATION WSURANCE /�DDRE55 ,5 �j� srnrioN oePrH
(This section need not be completed if the work involved by the hl4NHOLE REFERENCE 11PPER
IOCALRY Diamond Bar ,o,�,ER
permitisforonehundreddollars(5100}or�E45.� NEAREST Golden Springs/Carpio T�PEOFCONNECTION IENGTMFROM
I certify ihat in the performante of the work for which ihis cko555T. r. cues P.L M.LT07.1.
permit is issued,I shall noi empioy any person in any manner P�Nq
so as�o become su6ject ro the Workers'Compensation laws. owNex CO.IMi.ND. J08 NO. 6
��� TRUNK PERMIT NO. ROAD PERMIT NO.
Daie APPIiCOnt � /DDRESS
� �TICE T� APP�ICANT: If, after makiny ihi5 CPr�i{iCa�e Of �,TYCovina ` �rE,:•�c,:. 67-9541 AFFIDAVIi WAIVER EASEMENT RECAR�.INSiR.NO. DATE
mption, you should become subject to ihe Workers' �EGA� `
�Compensation provis�ons of the Lobor code,you must forrhwith oe5cairnoN iorN .� Hwv.oe sr.wioeNiNc
comply with such provisions or this permit shall be deemed
f2VOkBCJ. ' BLOCK TRAC STATEEY[ROACHMENT
�OF Bl�GS. 7ERMIT NO.
LICENS@D CONTRACTORS DECLARATION size or ior "'�� �r�ow oN�OT
1 hereby affirm that I om licensed under provisions of Chopter U$E OF
9(commencin9 with Section 7000)of Division 3 of the BUSi- BUIIDINGS
� CMARGES
ness and Professions Code,and my license is in full force and T
BffCCt. . CONTRACTOR R�C.R. P lumb ing� J.TZC. CONNECTION CHARGE FEE }
�
Llcense Number �f 7�_i n n LiC.C�a55� AO�RE55 agno la. V e. REIMBIIRSEMENT FEE Q
COr11fOC���M���,�,�DOte Y I��R 6 CIN TEL.NO. DISTRICT NO. GROUP MAP PROCESSED BV V
BK PG O
❑I om exempt under Sec. of the L.A.Co. iiceNse No. clnss l� �
No- DESCRIPTI N OF RK FEe
PlumbingCodeand/orSec. ofthe � vwni W
HOVSESEWERCONNECTINGTO y DATE �+ VAUpA ION 0.
� � PUBIIC SEWER I [ �—' � y y�
8.8 P.Code for the following reason SEP71C iANK,SEEPAGE PITOR FINAL �
>Ii5 AND/OR DRAINFlELD
Date FqUSE SEWER CONNECTING TO BY
PRIVAiE DISPOSAI SVSiFM
$igna�ure CONNECT A�DITIONAL BIOG.OR �
OWNER-BUILDER DECCARATION woeK ra Nouse sewea
OVERFLOW SEEPAGE PIT,�RAINfIEID
I.hCre6y affirm thal I am exemp�from Ihe Contractar's License exTN.,cessao0�,oavw�u,xtnNHO�e �I l�
� for the following reason(Secton 7031.5�BUISfIC55 OI1CI P!O- AIiER,REPAIR OR ABANDON HOUSE �r'� C� i hi
.iOns Code}: SEWER OR DISPOSAL SYSTEM , y
�'I'.t�. f �n 1 �
❑I,as owner of the property,or my employees with wages as
iheir sole mmpensption,will do ihe wo�k ond ihe siructure � . .� ���'F�G 7.J V
is no1 imended or offered for sale(Section 7044,Business
ond Professions Code�. OWNER�S Permit . a �Q O �, .., s r,���r�;i.,�
❑I,as owner of ihe property,am exclusively contracting with AUTHORIZAT��N TOTAL FEE /`�'`l t.L
licensed coniractors to conslr�ct ihe proiec�(Secfion��44, I MAVE AT THIS�ATE A CONTRACT WITH TNE HEREIN NqMED CONTRACTOR TO ��;'.i�5"V l:
BUSi�eSS Of1CI P�OICSSiOlIS CO(ICJ. CONNER THE A60VE DESCRIBE�EXISiING DWELIING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY ►
I hereby pffirm ihat fhere is p con5lrucfion lending agency SIGNEDTHIS DAVOF 19,_,
for the performance of the work for which this permit is O�ER oR
OWNERS AGENT -
issued(Sec.3097,Civ.C.). � �
nooaess
Lender's Name
Lender's Address
I certify IMat I have read ihis application and s!ate fhal Ihe
obove information is torrett.I ograe fo camply wifh all County . �
ordinances and Slate laws regolating Plumbin9 and Sewers, . - . �
and hereby authorize reprasenta�ives of this County to enter
upon the a e-mernioned pr ry for inspecrion purposes.
RCR BY, ���� 7/31/86
Signature of Permittee Dote SEE RfVERSE FOa EXPLANATORY IANGUAGE
' r,_ .�.�'��..-�".�.�4r+ f.•.
� iwsr�cmxs Nor� ow�vER Bt�II:Dffit D$C�RATroM
APPROYALS o..,r� iwaveerars s�wa� I hereby aHirm thrt I am enmpc trom the Contractarc's
r,�,�y� Licenae Law tm the Sullomiag rmon(SwcNaw 703Y.3,
Bwinar w�d P►afeuioiu� ead��'A+�y eiy a'maw�y
�o � � . wbicb ns¢rJ�+a s pwmit t�o cansbvet,alt�n deip�ow,
� �p
� -��g� .d+�ar npdr ierq+P�eta+v.Prfm'!o ih im�anar,
��onAttar�.o alro requieys tLr�e for swcb�►wiit w JJ(a a
cts,semi❑ oervau O s�qwpd sf�t les�11 ltmrrwd pdrnwt to tbt
Arovudo+u af t6a Cosmumeh lefanFRe L�v l�+aw 9
"� (�Ad a+ieb S�ffos 7QWl�k uJE INxddos 3 0�rbs
Bwsi�eu aad PtoJ�Cadt/or tbae Ba!s suaept
ae��r�se'�°Dwek tb�awd tbs 8mie Jnc tba a/lg�pl�xn���ur.Awy
enarnu�t ++iekkaw a¢'SscY�w.TQ3�l.S byon��t:Jona�raiit
sBt� E'� m� swbj�cts tbs oppdkvsa to a r.idl oJwoe nm►s ebmr
1�brrd+rd doTlas/�500�1:
�I,as t6c owner offl[e adll�tHe�a.►.ud
tha smicrare u mx' or a�Le[ed for�e:
fS+c. 7044,B��apd C,pin T8.-.:ois.
anclur's Zia�es� Lsm daw�at m as owissr u1
Zaes
pnoparby+nlw baildt oi ,mud+vltudoes
sweG wm�k�a+�` tJ�F�(i bnpeove�usst�
mv wot ixtaad�d a' jor rq/a�8arwws;tb�
. . haildt�q o'�t iE+otd o�s ysw'of
caoPJrtiw. flw aro�a�dld�wd11 ha�r tke bsatdas
. . oj pnovi�g tboe bia dJd wot 6�ptld or�prow JaR tbr
parpws oJadn/
I atD�Ps�Ct S�. ,
B$c P.C.faar tMc r�
. Date
O�
rn�croxs wores '