HomeMy WebLinkAbout1264A WORKERS'COMPENSAtTION OECLARATION � � �� � -� � - � � � � � � - �
I here6y offirm thm I have a certificate of mnsent to self
insure,or a certifimte of Workeri Compensation Insurance,or �aneazo
acerr�fiedcop thereo-f SSe�.,38D0,LabC.) CEBOB(REV.B/81� APPLICATION FOR PERMIT
Poi��r�$6�21.:fk�mpan�F'remont Indemnity �. C
❑Cert�fied copy is heraby furnished. SEWGR- SEWAGE DISPOSAL
.�Cert'rfied copy rs filed with the couniy Iding inspecti 530/ COUNTY OF LOS ANGELES BUIL�ING AND SAFETY
deportmeM. � ����.��.���_�_
oa�e '�!��(.a��pplican �4�I�`32WCXi FOR APPIICANT TO Flll IN CONNECTION DATA
CERTiFICATE OF EXEMPTION FR M WORKERS' euiioiN� � e C STATION oev�n
COMPENSATION INSURANCE - nooaess
(This seclion need not be campleted if fhe work involved by ihe ryWNHOLE REFERENCE � UPFER
permit is for one hundred doliars($100)or less.) ��^��TY Diamond Bar iowFa
NEAREST Golden Springs/Carpio TYPEOFCONNECTION �NC7HfROM
I certify�hat in the performance of ihe work for which this caosssr. r. cuas BL M.170P.1.
�permif is issued,I shall not employ any persan in any monner
� so as to become sob'ect�o tha Workers'Com ensation Laws. P.c No. 'j /�
I P OWNER CO.IMP.NO. J00N0. ��,J W
��� TRUNKffIiMITiJ�. ROADPERMITNO. '"
Date ApplicaM /+DDRE55 _ � P8Y V� . -
f-.�T ., AFfIDAVIT WAIVER EFSEMENT R[CORO.INSTR.ND. DATE
ICE TO APPLICANT: If, ofter making this Certificate of ctrr Covina � `��`TE;:°,�t>., 6,7-4541
mption, you should become subject to �he Workers' ��qi ���� �
Compensafion provisions of the Labor code,you most forfhwith DES[RIPTION i NO. � HWY.OR 57.WI�ENING '
mmply with such provisions o�this permit shall be deemed ,y
reVoked. . BIOCK ACi S1ATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION .OF a�oGS. PERMii No.
512E OF LOT NOW ON LOT
1 hereby affirm that I am licensed onder provisions of Chapter u5E OF
9(commencing with Section 7000J of Division 3 of ihe Busi- guitwN�s R s' n 1 cHnre�eS
ness and Professions Code,and my license is in full force and T
ef4eCf. CONiRACTOR R.C.R. P lumb ing� ln�.'. CONNECiION CHARGE FEE r
licenseNumber 7�7L�o�_�iC,C�055�2L- AOORE55 agno Z`c�. ver REIMBURSEMENTFEE Q
V-JV
COfIfIOC�rR PT.iTMRTAil: Date7�I�RE] CITV iEl.NO. � DISTRICTNO. GROUP MAP PROCESSEDBY V
SiqTE lIC BK PG � O
❑ I am ezempt under Sec, of the L.A.Co. ucENse No. ctass _ f(} �.
PlumbingCodeand/or5ec. ofthe �� �ESCRIPTIONOFWORK FEe � FiNA� // W
Fi0U5E SEWER CONNECTING TO �fr ,.-� pATE ..� (1 J�"J VALIDA ION p,
B.&P.Code for the following reason PUBLIC SEWER , �
SEPTIC iANK,SEEPAGE PR OR �
PITS AND/OR ORAINFlEW fINAL � ?
�01B HOlJSE SEWER CONNECTING TO B� / �
GRIVAiE�I5PO5AL5Y5REM ���'��i`r�l
$i9natUlE CONNECT A��ITIONAL BLOG.OR �
OWNER-BUILDER DECLARATION woeK ro i+ous�sewex
OVERFIOW SEEPACaE PIT,DRAINFIELO
�b.ereby offirm that I om exempt from ihe Coniradar's License EztN.,ceSsvoo�,oa'rweu,n,wNHo�e .
� for�he following reason(SEC1011 7O3I.S,BIIISl1245 Oftd P!O- AtTER,REGAIR OR ABANpON HOUSE
.Ions COdeJ: SEWEk OR�ISPOSAI SVSTEM
❑I,as owner of the property,or my employees with wages as
their sole compensation,will do rhe work and the siructure
is not intended or offered for sale(Section 7044,Business
and Prafessions Code). OWNER'S Permit _s � [�
❑I,as owner of ihe property,am exclusively contracting with AUTHORIZATION TOTAL FEE �:i �'�'����R
licensed contractors to construci the project SSection 7�44, I HAVE Ai THIS�ATE A CONiRACT WITH THE HEREIN NAME�CONTfiACTOR TO �
BUSin655 qn(J PfOfB5510n5 CO(IC�. CONNECT THE ABOVE DESCRIBE�E%ISTING�WELUNG TO TME PUOUC SEWER. �� m ...��. � [;
CONSTRUCTION LENDING AGENCY � .
I hereby affirm that there is o consfrVction lending agency SIGNEDTHIS DAYOF 19_ � � o r c 7,�.�?
for the performance of rhe work for which this permit is owNea oa
� issued(Sec.3097,Civ.C.). owHeasncerir � �. �„��i._,,T
nooRess
lender's Name
OS t[����f�
Lende�s RddreSs � � .
I certify thot I have read this applim�ion and state ihat the �
above informotion is correct.I agree ro comply with all Coonry � ..
ordinancea and State lows regulating Plumbing and Sewers,
and hereby puthorize representatives of�his County fo enler
upon the oba -menlioned pro ert�y for inspec�ion purposes. .
RCR BY;�.���„�, 7/31/86
Signafure of Permittee Date SFE RfVERSE FOR EXPLANATORY IANGUAGE
�r tl�� � r '� R�
i � �� � 4 . �. t�
� �� �
ir�s�crom Noa� OWNER•HE�:DBR DBCLAgA°1T(7I�F
A� QV/,�' OATE � INSFBCfOR'S9WNkTtitl ��1![l�e�PAl�dt�flfp�li9AQ1�l�/tb0C.�8C[M�t
�w Hous�sEwex ,tr� License Lw foe the foibw�ng remson/S�cdow 703I.5,
Bsaiwea owd RoJwiau Codrk Atry dty o'oorusy
�p�7 D
�911fpIMp�� i ' whu'b»4an+a u fNf�t�i to'G�f�pt�alhry 1r77�1ow
���,y.y�,5��p�P1t(5) ��MN D/k11.M'f�t�ll�'�s�jl/{Of IO�6 10Y6110B,
11f�/-bACRlUTIP18D � olro ftgFtn'a t6�OpP�(Gd�E LOs tACG A�iL Ao JXs O
:G�SPOOI.❑ pRYWfit❑ . nBNQ�s�BIqBDf lbBF jfi$�IId pY/SYO�t W t1/1
"'�'��� p.o�o,��s�e�a�.ua�.r,a�,�etx�pm 9
(co+�meKci�g+nlrb S�ow 70QOI 9IF Dinklo�3 qf eba
aeooroa�t a aoo ��P+'�f�+ Codel or t�O ba tc etanpa
tis�NooN� tb�re(�oa�ard elw b�oric for tbs oll�qnd dwY
enawtt�rawss p . � vio7utiaw ojSatNow 7033.5�!�9 . �6P�+*�i
�►, p cmnovks❑ mbj�cts tbe appJkmrt M i c1d1 ojwoE wwa+r sbaw
fha bradred dolfat/iS00��:
O I,n thc ooma afthr adil`datHraro•a e�
the stroctme is not' aE a�[�[d fucy�
(Se�c. 7644.Bechx�w�d Cadn�'tw CoR.
. amemr'�71rowe fAv�pc+eu to ma mal�es qf
property+o6e b�eildt w ferp�oo�t�irso�,ar�d wlw dov
awcb r,m�i 6inrr�piodd�d ek��i mreb ta�provam�nb
an wot a�Weded or o�tivd jar ads.�(/.�tarrtor, ebe
bniktiag ar l�proer�n�e b+o1d urit6fw or�yrw'ql
cm�pbtio�, sh� ounun6alldor wJll hae�t!u brrdaa
'. ` oJ proatqg tluu ba ald�wt ioJld o�ferproor Jur ebr
Pw►posp of+al�.l
I am exempt��qc.„_,_..�_.
B 8c P.C.for thic t�aaoe.
Date
O�aaei
INSRECfORY N07R