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' WORKERS'COMPENSATION D€CLARATION '
I hereby affirm that I have a ceriificate of mnseM fo self . �
insure,or a certifimte of Workers'Compenwtion Insurance,or ienaaso
a certified cop �ha.ao_F,{sa�.3800,lab C.) CEBOB�REV.B/Bi) APPLKATIC)N FOR PERMIT
vou�,�}$ 21' YSC�mpan�Fremont Indemnity o,
❑Certified copy is hereby furnished. � SEWER - SEWAGE DISPOSAL
�Certified capy is filed with tha counry ilding inspecri � 530/ COUNTY OF LOS ANGELES BUILDING AND SAFETY
departmeM.
Date �/_��Js7�ppliconm�� ` FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OP EXEMPTION F M WORKERS� BUIIDING / � p srnnani oevTH
� COMPENSATION INSURANCE AO�RE55 L�
(This sec�ion need not 6e completed if ihe work invoHed 6y ihe �p�q�ITY Diamond Bar M^.NHOIE REFERENCE UP?ER
permit is for one hundred dollars($100)or less.) �OWER
I ce�tify that in the performance of�he work for which ihis �Ro�ss,. Golden Springs/Carpio TVPEOFCONNEGTION �ENGTHFROM
�. CURB P.l. M.l.TO V.L.
permit is issued,1 shall not employ any person in any manner v.c No. `�
so os to become subject ta�he Workers'Compansation Laws. owrvea CO.IMV.NO. JOB NO. O,1
��� • iRUNK PERMIT NO. ROA�PERMIT NO.
Dn�e Applicant nooaess �
� 110E TO APPLICANT: If� OfiCf making �hi5 Certificate Of [ITY Covina � � TE�.`"`"16�-9541 AFFIDA4IT WAIVER EASEMENT RECORD.INSTR.NO. DATE
�.,amption, you should become subject to ihe Workeri �E�� }� .
Compensation provisions of the Lobar code,you must fonhwNh � oe5ceipnoN . i No.D Hwv,ok 57.wioeNwG
comp�y with such provisions or}his permit shall be deemed
lCVOk9CI, BLOCK RACT SiATEENCROACHMENT '
LICENSED CONTRACTORS DECLARATION �DGS. a�Rrnii NO.
SIZE Of�pT � --" -OW ON LOT
I hereby affirm ihat I am ficansad under provisions of Chapfer uS�aF
9(tommencing with Section 7000)of Oivision 3 of fhe BU51- BWLDINGS [Hn2�es
ness and Professions Coda,and my licenae is in full force and •
effeci. coNrua,cToe R.C.R. Plumb ing� IriC. CONNECTION CHARGE FEE �,
a no ia ve. a
License Number_nrn r i�n n_Lic,Cbss� nooaEss g R[uneuR5En4EM FeE p
CanttOC� Date Z����$� - � . oISTRICT NO. GItOUP MAP FROCE'aSED BY V
CITY TEL.NO.
8K PG O
❑I om exempf u nder Sec. of the L.A.Co. LiCeNSE NO. ci 55 _ 1� F
NO. DESCRIPT�ON OF WORK FEE (J
Plumbing Code and/or Sec. of ihe pwni
W
HOUSE SEWER CONNECTING i0 /y DAiE
PUBLIC SEWER I/ �� r� �
B.8 P.Code for the following reason s�Pri�TANK,seeva�e vir oa IDA ION y
GIiS ANDlOR DRAINFlELD FlNAL �
Date HpUSE SCw[R CONNECTING TO B� ��(�;GLr-'�
PRIVAiE DISPOSAL SYSTE
Signature CONNECT ADDITIONAL 6tDG.OR �
OWNER-BUILDER DECLARATION �M1'ORK TO MOUSE SEWER
OVERFLOW$EEPAGE GIT,pRAINFIELD
i"'areby affirm that I om exempf from Ihe Contracfor's license ezrN.,cessPooi,oerweu,mnNHae
��for ihe following reason(Sec�on 70.31.5,Buisness and Pro- a�rea,aevqie oa nenNooN Hous� y� 1,
tessions Code): SEwER oR oI5P05AL SvSTEM �%- � �5 4`I'1
❑I,as qwner Of fhe property,ar my employees with wages as };4 Q a � � �l
their sola tOmpensation,will do the work and the siructure
is not intended or offered for sale(Section 7044,8usiness - � z,.0 2�,��
and Professions Code). OWNER'S Permif E �,�j'�
❑I,as owner of ihe property,am exclusively contracting wilh AUTHORIZATION TOTAL FEE Q "'`� °i f.��l� .
licensed tonfractars to construcf the projetf(Settion�044, i HAVE AT THIS DAiE A CONTFACT WITH THE HEREIN NAMED CONTRACTOR TO f-7 F�,
BU51nB55 On(J Professions COfICJ. CONNECT TME ABOVE DESCRIBED E%ISiING DWEIIING TO THE Pl1BlIC SEWER. D i.�L� �C7
CONSTRUCTION LENDING AGENCY ►
I here6y affirm that fhere is a construction lending ogency SIGNFDTHIS DAYOF 19_
for ihe performance of the wo�k fo� which this permit is owNEROR
OWNER$PGENT
issued(Sec 3097,Civ.C.).
ADDRE55
Lender's Name
lendar's Address
I certify thai I have reod this application and�stale ihat the �
above information is cwrect.I agree to comply with oll County �
ordinances ond Sfale laws regulating Plum6ing ond SewerS, � �
and hereby au�horize represenlativas of this County to enter �
upon ihe a6 -mention pro rty for inspecfion purposes.
RCR BY; ,�, 7/31/86
Signofure ofPermiifee Dote SEEREYERSEFORE%PLANA70RYLANGUAGE
3
� �+.������#�'���ia�•�
� ���R�N� OWNER-BY3hHBI2 1�$�LA�fll'T101ri
APPROYALS w�re na�srors sux�,tnxE I hr.eby sffitm thac I em exempi h�e tMe Cawttaemrr's
/ License Law for the fallo�np reeva/S�eiinw 7031.5,
New�[snv�x . . � B�as awd I+�fadau Eadek Au�y ag os cossty
�� +t+bicb rrrqeeirss o peew�it ro cna4post,o1�71r,kuprow.
.+�i�� � � � ������
.assroo�.❑ wvwat O s�ed s�t t!u#b�Jr�asd pwa4arst to i6t
A�+�*qf�ba Canhuc�ars I,�te[ipo I�LuRa.9
a (connsac�nd asitb S�7p017�oj Dlaettfos 3 qf rtra
� Hunwsu mrd Frofita�t C¢�l ar ebot br a sorapi
��� � . . tbarofinn.m�d tbs badefor tln sRrdrd Awy
�a�Srr�703�t.$�•�lt�ti os� �p�mlr
tbr t w a elci!
�rrt O�s❑ ��/,ff� nf,wtnror.tbaw
❑I,as Hx owner af tLe �el1t do ttte�v{-`en�
the etrnetaee i�aot �a��s�'
(S«c. 7044.Badew eud Codt:�ir Cow-
ancYa'i Lrnwe Isw don+wt to mt mvssr n1
property to�bo b�rffds or hwjnoo�t nd rntw dorr
rneb�unr,i 8nnn�(/�eb��npc�e�ova�wb
�a�wt iateadrd w�Md Im'+,�i ,�tayv�r,t6e
buiAdte+q m+�spraoomr�t ii inld�ans y�sr 9f
rnmAhpoe. tbs o�rildar w1R bruo t6a bwdeu
. . . . . of pr»e�hrg tbat be did Mot d�lld or i�xpiwM Jer eber
pmpwa oJrAJ+I
I 8�C7C�0l�t D11S�['�1kG�.—,
- - $�[P.C.fGa'tb1S lCBBQD
Date
Owner
1lRPECTOR'S NOf� � .
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