HomeMy WebLinkAbout1262A � �OMVE/JSAiIOM1t DKLRRATION q
I hereby offi�m �hat I have o cartifica�e of consan� ro self I�
insure,or a certificale of Workers'Compensotion Insurance,or �bAea2o Lt
°`�'�`g��''P`3�mP��'rem`o�t Indemnity �,BOB�R�.B�e,� qppIICATION �OR PERMIT
rou� o,
�Certified copy is hereby fumished. SEWER • SEWAGE DISPOSAL
Certitied copy is filed with fie munty 6 'Iding i�specrio 530/.3� COUNTY OP LQS ANGEEES BUILDWG AND SAfETY
departmen�.
Dote 7/�1 /R�pplimntRC'j; $�• 14h�. FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EKEMPTION FROM WORKERS' aunoiNc O 5rqt�ow pePTH
COMPENSATION INSURANCE nooREss
�This seciion need not be completed if the work involved by tha i�in� Diamond Bar MnNnae aereaeNce iowE
permit is for one hondred dol�ars(5100)or less.) �
�certify that in the performonce of the work for which this ceoSSSSr. O en pT1Ag5 Carpio TYa�oFCONNeciionl IENGTHFROM
permit is issued,1 shall nor employ any parson in any manner �� c�Re P.� M.�,To P.�.
so os ro become s�b'ect ro the Workers'Com ensa�ion Laws. o.c.No. '7�
I P pWNER CO.IMP.NO. JOB NO. O��J
�L 1074 PHTk VZ[�eW .D[�T. TRUNKPERMITNO. ROADPERMITNO.
Dote Appliwnt nooRess
/'"`TICE TO APPLICANT: If, after Mtlkin9 ihi5 CBIiI{iC010 Ot �ITY ��V1na' ��� 7EL" 767�7541 AFFIDAVIT WAIVER EASEMENT RECOR�.INSTR.NO. DATE
� mption, you should become suhjed to the Workers' iE�At ��
Compensation provisions af the Labar code,you must for}hwith � oe5ckittioN i0 r�0. nwv.Ca St.wioeNiNG
comply wifh s�ch provisions or this permit shall be deemed
fCVOkBd. BIOCK iR T SiATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION . . .��oF�°�s. ��.+iT No.
512E OF LOT � NOW ON LOi
I here6y affirm ihot I om licensed unde�provisions of Chapter us�oF
9(commencing wi�h Section 7000)of�ivision 3 of�he BUSI- BUILDINGS Residential �HARGES
ness and Professions Code,and my license is in full farce ond Q .
Clfe[f. CONTRACTOR � um n0� InC. CONNECTION CHARGE FEE �
LiC@nSe NUYftbel ���,091,�_I�7 St LIC.CIP35 v� A�DRE55 e� REIMBURSEMENT FEE Q
Contro��R PLUI�ING bare7f�].f 8b ' . oisraioNo. caouv rnna PRocesseoar V
❑iV TEI.NO. gN GG Z
❑I am exempt underSec. of fhe l.A.Co. iiCeNSe No. cwss � �1—
PlumbingCOdeand/orSec. Ofthe NO. �ESCRIPTIONOFWORK �E � FiNAL V
HOUSESEWERCONNECiINGTO /�'7 ,� OATE ���� VqIIDATION �
B.&P.Code for tha following reason Pueuc Xweu ! N
SEPiIC iANN.SEEPAGE PIT OR FINAI z
PITS AND/OR DRAINFIElO
Dafe HOUSE SEWER CONNECiING 70 BY
PRIVATE DISPOSAL SVSiEM
$i91tp1Uf0 CONNECi ADDIiICNAI BL�G.ON ' �
OWNER-BUILDER DEC�ARATION woaK to rrouse sewea .
OVERFIOW$EEPAGE PIT,DRAINFIELD
�,}zereby affirm�hot I am exempt fiom ihe CoMrac�or's License ex7N.,cessPoo�,oavv.�u,M4Nhioie �
� for�he following reoson(Secton 7031.5�BUISlIC55 OOd Pf0- ALtER,REFAIR OR F9ANOON HOUSE
,iOf15 COGIBJ: SEWER OR�ISPOSAL SYSTEM ��
❑I,as owner of fhe property,or my employees with wages as �� I �����F �
their sole compensotion,will do the wark ond�he strucNre �, s c e '(�
is nor inrended or offered for sale(Sectlon 7044,Business / D ' 4 ��
and Professions CodeJ. OWNER�S Permit y � „.�,��,5(
❑I,os owner of the propory,am exdusively conlracting with AUTHORIZATION TOTAL FEE � �
licensed coniractors to consfrutt Ihe project(Seclion 7044, 1 HAVE AT THIS DATE A CONiRACi WI7H TNE HEREIN NAMED 40NT2ACfpR TO 4r`'�'��� r��'�'�-
BVSI�C55 O�CI P�OFESSiO�S COIIE�. CONNECi THE ABOVE DESCGIBE�EXISiING DWELLING i0 THE GUBIIC$EWER.
CONSTRUCTION LENDING AGENCY , O'7 G�`S C?
I hereby affirm fhot fhere is p construcfion lending ogency SIGNED7HI5 DAYOF 19,,._
for the performance of the work for which tbis permit is owNes oe .
OWNERS AGENi
issued(Set.3097,Civ.C.). Av�RESS
Lender's Name
tender's Address . -
I tertify ihat I have reod �his applicatian and stata�hai the � �
above information is mrrecf.I agree to<omply with all CouMy -
ordinances and State laws regulating Plumbing and Sewers,
and heraby authorize representalivas of this County lo enter
upon the obo mentioned pr erty for inspection p�rposas.
RCR BY; �t�'�, 7/31/86
S�g�o�ure of Permiltee Dote SEE REVERSE FOR EXPLANATORY LANGUAGE
��� �, • � s.,p. , � a �
� �'1�� �' . ?' ��� ��' ���! �r�� ' '�
ti ,�.,:� �
INSPEGTORS NQTES , OWNSR*SL4II:DSK'D�Q.A'�Y�I�N
APPRQVALS aa� � mneeer�r:s s�rtasurt� I hereb�atGrm ehat I am exemp[feum the Conttaetw's
License Lnv ior t6e xeatam/SaeAton 7031.3,
�w fqusi stw�x � �.g � Brsfweas�m�d R»fasirwsoa�Cn�ek Atty dq or coawty
an
eU�� . wbicb s�wwrnec a prrmit ta ovwpsref alia',ineproo�.
gyrtC T �� � drmoNvb,or�rpah(o►�strsielorr.Prlo►ro bs fawwc►.
`ANDio��liD . wlro s�gpira tb�a�taaat fov�,rrCb)wrn�iE to fUo 0
s;gnrd,mtr�newt tl�s 6e i��2s�o�pYrrrant tb tlx
cmwoo�Ll oawau D prouieiows oj tba C�}Iinesw law/Cb�rrr 9
��e�� . (m+nfaeMd*r8 witb S�eNaw 7QU0�a�Dta4iw 3 oJ tM
H�rinese awa?PioJetdoss Catr)m�tbai bs is savmpt
a+x� � ' � tbarefio�nr aed elw bwJt jor ttw q(fg�ssusptioe�•d+sy
y� � -T -[] � wolatiofsofSmlio��0�l.Sbywy4ppPlmstJorap�nsti
`s� . C�s1a�5❑ �rbj�ctf tb.r�t to a doilpeilrtliy of�trot tdors tbas
� ./hra brndred dollarr/SSQO�r
❑I,es the omna at the propeRq wtlldothewo��ud
the ateutture u aa intmded or of�ed f�sde:
(S�. 7044,Hwiaea a�d Profiastass Cadas 77w�;oe.
iinc�or's L,icsRs�Lav dOu woe�piJ to aa oruwn of
proparry wbo bsiGLt w bsproua ebmne,aui wbo doer
ara�i worA Mrert�P�ocW�d tbat mcL�wprownrMb
aro not i�tmd�d or oj�ind far�q7k.�(,b�ner. NH
brildieg ar�t 1s avfd+odtlnhF ow yqr of
cmwp&tio�r, t�6r o�os�nbrtfdN ra�A Gsoo tbe bwdan
• of prm�irg tbae J»ddd wor brlld w{mproar jon fbe
PurPose oj+olQ.f
� . . I'8ffi CI�]R 1���.�,,.,�.
� g�•F��"r-�L��ti�9AF
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IN4PECFOR'8 NOTES ._..
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