HomeMy WebLinkAbout1253A - 'CENfR MSATIOIV DKLARATION
I heraby offirm thot I hove o cerfificote of consent ta self �
f insure,�or a certificate of Workers'Compensation Insurante,or ianea2o
°`°Y�'$��3�'i'�°��mPo��'remont Indernnity �,°��REve,ei APPLICATION FOR PERMIT
Pou�
�Cerfified copy is hereby furnished. � SEWER • SEWAGE�RISPOSAL �
Certified copy is filed with tha county ilding inspecti 530//L- COUNTY OP LOS ANGELES BUfLDING AND SAFETY
department.
Date 7_,_.�?l,�Rbpplicant fOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE Of EXEMPTION FROM WORKERS' D � �
COMPENSATION INSURANCE � nooaess `~ sinrtoN oePrH
(This sedion need not be mmpleted if�he work involved 6y�he Diamond Bar n�^,NHOte a[-�EReNCE � uvPea
permi�is for one hundred dollars($100)or less.) �«'4L1TY �ow q
NEAREST Golden S rin s Car 10 TYPEOFWNNECi�ON tENGTHFROM
1 certify�hat in fhe performance of ihe work for which this [Rp5S5T. P g P� v. ��RB p.l. M.L,70P.L.
permit is issued,I sholl not employ any pe�son in any manner � c.c.r+o. ?
so as ro become subject�o fhe Workers'Compensation Lows. ownea � � co.iMP.No, � �oe No. ���J
'��� TFVNKPERMITNO. �ROADPERMITNO.
ADORES$
Dote Applicant r
qfFIDAVIi WANER EASEMENT RECOR�.INSTR.NO. DAiE
r�TICE TO APPLICANT: If, afler moking this Certifimte of �itYCovina 67-9541
smption, you should 6acome su6ject to ihe Workeri ��Ai
Compensation provisions of the labor code,you must forthwi�h � oe5ceivrioN � o. HWv.oas*.wiDeNm�
comply with such provisions or this permit shall be deemed
- revoked. B�OCK STAiE ENCROACHMENT
�� � LICENSED CONiRAC70R5 OECLARATION � -� ' .�oF e�°�s. PfRMiT No'
SIZE OF LOT NpW ON LOT
I here6y affirm that Pam licensed under provisions of Chapter uSeOr
. 9(commencing with Sec�ion 7000)of Division 3 of the BUSi- BUIL�INGS criae�es
ness and Professions Code,and my license is in full force ond /+ T
2ff@Cf. � CONTRAC70R �•y•R. P lumb ing� lnC. CONNECTIpN CHARGE FEE }
LiCense NUm�Jel 'J�JLp/�iIIQ_�iC,C�OSS�,6____ ADDRE55 agno ZC� V e. REIMBURSEMENT FEE O
Contractj�{'R PT.�$TNC:Date�!�I�p6 � PISTRICTNO. GROUP riwv vaocesseoer V
CITY TEL.NO. ^ BK PG Z
STATE LIC. 0
❑I am exempt under Sec. of Ihe L.A.Co. uceNse No. C�nss _ C� �
Plumbing Gode and/or Sec. of fhe N�� DESCRIPTIpN F WORK rEE � F�NA� .
HOVSESEWERCONNECTINGTO / DA7E � �:, VALIDATION �
8.&P.Code for ihe following reason PUBUC SeweR � � N
$EPTI�TANk,SEEPAGE Pli Ok
pITS AND/OR pRAINFIELD FINAI /j �
Dare NOUSE SEWER CONNEC7ING TO 8Y ��/,L��t,y✓2
' PRNATE DISPOS4L SYSTEM
$IynOtUfE CONNECT AD�ITIONAL BLOG.pF �
OWNER-BUI�DER DECLARATION woRK To Hous�seweR
f-4ereby affirm Ihat I am exempt from ihe Comractor i License �N���C SSPOOI oxvd.'�iAi.inNHoie
for the following reason(SeCfOn 7037.5,BUISnE55 anCJ PIO- ALTER,REPAIR OR ABANDON MOVSE
'�as310n5 COdE�: SEWER OR DISGOSAL SYSTEM
❑I,as owner of fhe property,or my employees wifh wages as :_� c'J,.�i�i
�heir sole compensation,will do�he work and�he structure
is not intended or offered for sale(Sedion 7044,Business r. . c e��.' � �'
and Professions Code). OWNER'S Pe�mif S Q
❑I,as owner of�he property,am exdusively contracting with AUTHORIZATION TOTAL FEE .(j 1 " <�-c �,�.`l�
licensad contractors to conshuct fhe prole«�SBC110���4, I MAVE Ai THIS DATE A CONiRACT WiTH THE HEREIN NAMEP CONTRAC/OR TO
BUSIrle53 pfld VrofE89iOt/4 COC�C�. CONNECi iHE AEOVE DESCRIBED EXISIING DWEI.UNG i0 fHE PVBLIC SEWER. �� � �_ ,',��'.y�
CONSiRUCTION LENDING AGENCY �
I hereby affirm tha7 there is a construciion lending agency SIGNEDTHIS DAYOF 19_ � C�i;G�`��J
for the performante of fhe work for which fhis permit is O�'NEROR .
ISSu¢CJ($EC.3OJ7,Civ.C.�. OWNERSAGENT
AODFESS
lender's Nome � �
Lender's Address - �
I certify�hqt I have read Ihis applicolion and stote that the �
obove information is mrrect I agree to comply with oll County .
ordinonces and State laws�egulating Pium6ing ond Sewers, �
and hereby authoriza representatives of this County to eMer �
upon ihe pbo manlioned rop y for inspecfion purposes.
RCR BY; ��� 7/31/86
Signature of Permiflee Date SFE RE4ERSE FOR E%PLANATORY LANGUAGE
�� .�T� � • L�e � ; i `� . . �
� � ��; � .� r _� � f `
iNsvEcroRs rwsEs OVFIVEtt Bt�lET3��
APPROVALS onh iaa�c�ors�s�vnwa � I hereb7r effirm that I am enmpt froaa the C�metor'�
ncw tau�se�a � . Lioenee I.aw for tlte fallowing rmwn/Sartlos 7Q$t.f.
� . Bxsiwas and PMJarioiu Cade%d+ry chy a'eora0y
!U Q0.VY00.K
+vbicb+vqwres a p�rnr;e to rnw;erre7.uRor,irnyrow,
� � 3 . �IY0�1/.OR IiI� +/I�It�Ol hD�ll/�r
- O8O ff�MMA f�fi�f f0{'7Yi�fNflN�f f0�i 6
�Q35R�Ot[] �ItYU4L� . . �SfOtl11/J11 �(��]'L7NTfd-pYl1��fU t�f
Ama+ivwar oj eEs C�paee�'k IJctisr�I�o lCBqEMrr 9
9fl�'K���e hmirswaci+g mttb S�tbw�OdGI�a�/L71aWow 3 uf tbo
asoONr�cr .aro . . .. H.isrw.es a.d Pro�mlow+ Cady m rbat br is ean.pt
Aene�oON �a�[a ibn+a/rors mod ibs/wlttfar ib�aJl�g�d�nsp�taR,tlsr
+,iolatfaa a�Secebw 7Q32.S b9 a�ya�pl�mtt{ev agawdi
sE� CT cesxaois❑ sab�.cfxtb.appNuoetaudetvllp�raltyaf+wearoniEww
J!w beudird doJlpn(�fS001�:
C]I,es the mvaer o�f t6e wili dcthn eu}�"'md
the suuctw�e is nns' oi a�focp�,
/Sec. 7U44,$'tkrm asd Codtr�'lii Cae
t�m's Liciort�L�a d�watapp(y to as maen of
propart�r ud�o BriWs oi in►�d►noa t�e�x,gd+ubn doai
siacb�unrk�tt�protidwd tbat sreL iarpl000rn�wu
me�ot iwiondsd or o,�r�aC fm udn.�G bmmon,tb�
lwrJdiqq or i�i is mAd wl�bbt o�h,yreo�oj
. . cnenptataow. sbs�ueUl'lwor fbs bwdo�
. � � - . . . oJ proviwg thae b�did+wt bnild or Jsiprow jar eba
pwpate of mfwl
� I 8IIi E7k�'�tt imLiCl'$6:. �
H 8i P.C.fUL LI�i@ t�
Daroe
.. . ; [hnw�ar
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