HomeMy WebLinkAbout1251A WORKERS'C�MPENSATI�IY DECLARRitON � � � � � � � � - � �� � � � � q
i hereby affirm that I hove o certificate of consent to self � I�
insure,or a certificote of Workers'Compensation Insurance,or �eneaso ZS
a certified co «�� o Sea 3800,La6 C.) CE808(REV.B/BI) qpp��CATION F�R PERMIT
Pai;�,,[t�g86n�21���mpQ„yFremont Indemnity o:
❑Certified copy is heraby fornished. SEWER - SEWAGE DISPOSAL �
�Certified copy is filed wirh the county ilding inspec'on 530/ � COUNTY OF l05 ANGELES BUILDING AND SAFETY
department. �
�aia 7Tl�l'Rbpplicantur�. FOR APPUCANT TO fILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' eunoiNc C/ n � �
COMPENSATION INSURANCE nooaE55 � c., STATION OEPTH
(This secfion need not be compleled if thg work involved by fhe �p�Apiv Diamond Bar kaNHae aereaeNce owE
permit is for one hundred dollors($100)or less.)
1 certify that i the performance of the work for which this �RossssT. Golden Springs Carpio TY7EOFCONNECfION �NGTHFRpN,
permil is issued,f sholl nof emplay any persan in any monner �� CURB P.L. M.L TO V.l.
so os to become sub'ect to the Workers'Com ensation�pWS. P'�'N�' ,O,.�
I P OWNER CO.1MP.NO. JOB NO.
�'« TRIINKPERMITNO. � RO/+OiERMRNO.
Dqte Applimnt AODRE55 1 T�C. V� W �DT.
� SICE TO APPUCANT: If, a41er moking �F115 CEfIIfICO�E Of CITYCovina -��9�7-9541 AFFIDAVIT WAiVER EASEMENT RECORD.INSTR,NO. DATE
��emption, yo� should became subjec� io the Workers' �ECAi �
Compensation provisions of the Lobor code.yau must forthwith oescairnqv l 4No. Hwr.ORSi.wioeNiNc
comply with such provisions or this permit sholl be deemed ,t�-
reVOkBd. . BLDCK iRA $TAIE ENCROACHMENT
LICENSEDCONTRACTORSDECLARATION .�.• �ore�o�s. �eaMiiNo.
SIZE Of LOT NOW pN LOT
I herehy affirm that I om licensed under provisions of Chaprer useoF
9(commencing wiih Sectio�7000)ot Division 3 of the Busl- guaoiNcS crnR�Es
ness ond Professions Code,and my license is in full force ond
@HECI. � �ONiRACTOR �•�•�. P lumb ing� ITLC. COfJNECTION CHARGE FfE �
LiC2nse�lumbef '���v_/4=4Q_�iC.C�p35 _G '�,G ADORE55 agno 1`CL ve.. REIMBURSfMENifEE O
COnffOCity�.R PT.TTMRTNrDate,Z,��/�Fi CITY TEL.NO. . DISTfiICTNO. GROUP MqP PROGESSEDBV V
BK PG Z
❑I am exempt under Sec. of ihe L.A.Co. iic Nse No. cass _ � � �
NO. DESCRIP110N O WORK FEE / W
PlumbinqCodeand/or5ec. ofthe . FiNAt / VALIDATION y
HOUSESEWERCONNECTINGTO //f .�_ OAiE �J��9/V/°, N
B.&P.Code for the following reason vuauc sewea / � c x-
SEPTIC TANK.SEEGAGE Plt pR fiNA[ Z
FITS ANO/OR�RAINFIEI�
DO�e HOUSESEWERCONNECTINGiO By f`����t,� �
PRIVATE OISGOSAL SYSTE ✓.�
$i9n(SIV�e CONNFCT AWITIONAL BLDG.OR ►
OWNER-BUILDER DECLARATION woeK ro r+ouse sewea
OVEkFLOW SEEPAGE PIT,DRAiNFiEL�
f'"'breby affirm Ihat I am exempl from ihe Coniraclor's License - [xrN.,ctssvo0i.oxvwEu,,v�pNNoiE
�for the followiog reason(SECfOn 7O3I.S,BUi4f1CS5 Qfld Pf0- ARER.REPAIR OR ABANDON HOUSE
TBSSiOnS CO[Je�: SEWEROR�ISPOSnt SVSTEM
�I,as owner of ihe property,or my employees with wages as �
their sole compensation,will do the work and ihe slrucNre � i-
is not iNended or offered for sole(Section 7044,8usiness `�� �u.� F�
and Professions Code). OWNER�S PBrmii i
❑I.as owner of the propery,am exdusively tontmcting with AU'�HORIZATION TOTAI FEE � . f' `''m '' i �
licensed Coni�a[10�5 f0 construct the project(Section 7044, i HAVE AT iH15 DA7E A CONTRACT WiTH TNE HER�IN NAMED CONTRACTOR tp � � �; �;��t.�}
BUSine55 Ont�PfOf¢SSions CO[IE�. � CONNECi TME ABOVE�ESCRIBED E%ISTING DWELLING TO THE PUBLIC SEWER. -
CONSTRUCTION LENDING AGENCY � �� , �.'����;;��,z
I hereby a{firm ihoi Ihere is a construclian lending ogency SIGNEDTHIS DAYOF 19,_ ��
for the e�formance of the work for which this OWNER OR J.
p permit IS OWNERS AGENT �I E:,��'"'C 6
issued(Se<.3097,Civ.C.).
nooeess
Lender's Nome �
lender's Address � �
I certify thnt I have read this appiicotion and state that ihe �
above infarmation is mrrect.I agree to comply with oll County .
ordinances ond$fafe laws regulating Plumbing and Sewers,
and hereby authorize rapresentatives of this County to eNer �
upon the ab e-meMioned pro arty for inspeUion purposes. � �
RCR BY;��Q,l� 7/31/86
� Signature o Permittee Date SEE REVERSE FOR E%PLANAiORY LANGUAGE
�i � � �� -�� +i k, �J}� y � � � � I'7�'{�
��w
'�.}�.� �� �
iwsrEeto�rs worEs OWAfER B1�.D�t DBCL�4RR�'TIf7l�i
APPROVALS oa� iw�rrons saweaaua I hereb�r afffxm thst I amezempt ftma the�Camtnctorb
r,�,nouu s�,�yER License Law for the foLowiag e�fon(Swliow 7031.5,
� BksJn.gs rn�a A�ia�owe Cod.k�sy dsy u►eosaey
.�oxwor�' . .
w8reb ivqwber a pnnult ta earsinrcR elt�r, Jinprwa,
sept1c r w(s1 dkruollPh.or repah a�9'rxwdrY+s.�dor�tn!tr i�trwwn.
�MAiOR���tt.o alw r�ggpinr f6e appllaA�t for nrch�it m jIk a
-.�Swot❑ oR'�wut❑ _ aigaed afat�ma�t fLat 1»!!ll�sd O�t to!br
�wu
���� P+��of ebe Cmw�,mr'�LianKn Lrtai/C6yrter 9
/sonrm�+dtb Seetlas 7QUD/��Dbklo�3�sM
Bruiiwcr oad Arojsstfa�a CopbJ or tbae!w b e�nrp�
� a T g � - tbnsjro�m�d tbr baair jon tLe aW�ral esrrA.�i1°�•$n0'
eKacr Q viulafaowa,{SectEvw70�1.Sb�"at�"qDp'tlmwela'aA+�+�
5EF►. C} EeaeOa&❑ arcbjertr tbe o¢pRcairt ta a ch+ll pamliy of frot aww tlww
Jlw baadtvd doJlses/iSQOJ.e
❑I.as the oweer af t6e ptv�tq R(p do the mF tnd
the seructwe i�aot�n aa ofEaed fos aie,
/Sre. 7044,Br�am�iswbs Cader TTia�Cow
amaar'a Ilcrut�Lav dou+tot m as mmwr oj
pr�operey wbo 8rlldr or J�prouo t�Ow,r�d�daa
.sacb+ua+k bh��i pene6Jt�eltot spda�fs
ars»oi ister�d�ur yQ'uYd foc m1�.If,lman+e,tbc
� . bri7di+r�q or topmu�s�Mt$m41�uRa ywtr�
ca�9J+eiar, tle� o�asrnbrl/d�e+�(I 6was tb�6wdow
. . . . . o,�f p�oolwg t6nt b�d1d�oe bslld ar fn►Oroc�Ioe e6�
Pu�Pu+a of aeLr./
I am ea�pt D1I�C['$�C ,
B&P.C.fur this ra�snn
Date
�
� INSPECTOR'S NOTES