HomeMy WebLinkAbout1267A WORKER9'COMPEN&AiIOIV DECLARATION �
I here6y affirm that I have a certificale af consent fo self -
-insvre,ar a certifimte of Workers'Compensation Insurance,or �6A6<2o
a certified co y thereof Sec.3800,tab C.) CE809(AEV.B/81) qpp�ICATION FOR PERMIT
Poi��,W�86�32138c�mpon�remont Indemnity �,
❑Certified mpy is heraby fvrnished. �EWER - SEWAGE DISPOSAL �
�Cerrified copy is 4i�ed with the counry I ild+ng i specti 530/ �OUNTY OF LQS ANGELES BUILdING AND SAFETY
departmenL �
Date -r/���pplimn FOR APPIICANT TO FILL IN CONNECTION pATA
CERTIFICATE OF EXEMPTION FROM WORKERS' suimiNc q L+ srarioN � o[rrH
COMPENSATION INSURANCE Aooaess �p� s,, �C G
(This secrion need not 6e complered if the work involved by the �p�Apir Diamond Bar i+.>NHo�aeFeaeNce uPa�R
permit is for one hundred dollars($100}or Iess.J tOwea
1 certify that in the performance of ihe work for which ihis R�sssT. Golden Springs/Carpio T�a�oFcoNNecnoN t�N�THFROM
Y. CURB P.l. M.l.TO P.l.
permit is issued,I shal)not employ any person in any monner P�NO ����
so as�0 6ecome s�bject�o the Wo�kers'Compensation Laws. , ownea � co.imc.No. �oe No. �
��� - ' TRVNK PERMIT NO. ROAD PERMI7 NO.
Date Applicant .4WRE55 �
/`�"�� . ���-�-���`�. � qFFIDAVIT WAIVER EASEMENT RECOR�.INSTR.NO. DATE
� �ICE TO APPUCANT: If, ofter making ihis Cer�ificafe of �iT�Covina .� TE�:r�:% -9541
...,tnption, you should become subject to ihe Workers' tECAL
Compensation provisions of rhe Lobor code,you must forihwith oescrtivTioN �orNo. Hwv.ozsi.wioew�
comply with such provisions or ihis permit shall be deemed
ravoked. � � s�ocK ACT ''� STA1E ENCRDACHMENT
LICENSED CONTRACTORS DECLARATION . F etoGS. PEweii No.
SIZE OF LOT NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter u5E OF
9(commencing with Section 7000)of Division 3 Of ihe BUSi- 6UILDINGS 67ARGE5
ness and Professions Code,and my license is In full force and • -
effecf. � CpNTRACTOR R.C.R. P lumb ing� In.0. CONNECTION CHARGE FEE �,
a
License Number ']']L l.�]O �IC.C�oss agno �.a. Ve. qEIM8t1R5EMENT FEE Q
��— �'��� ACORE55
COI1�faC Date����Fi . � , DISTRICi NO. GROl1P MAP YROCESSED BV V
QTY TEI.NO. gK PG O
❑ I am exemp�under Sec. of ihe L.A.Co. iiC¢Nse No. clAss �� �
NO, DESCRIPTION OF W RK FEE ' V
Plumbing Code and/or Sec. of the FiN'°i r / VALIQATION a
HOUSE SEWER CONNKTING TO �0.TE �,-�y�
PUBUC SEWER � 7"7"' -A 7"
� B.&P.Code for the following reason �pT��TpNK,SEEPAGE PIT OR / �
PITS ANO/OR DRAINFIELD FINAL ���L
Daie HOUSE SEWER CONNKTING TO BY �
PRIVATE�ISPOSnL SYSTEM
$i9r10iVEC CONNECT A�DIiIONAI BLDG.OR �
OWNER-BUILDER DECIARAT�ON woaK ro rrouse sewea
OVERFLOW$EEPAGE PIT,pRAINFIEID
t-�reby affirm tha�I am exempt from the Contraclor's License cxrN.,cessrooi,oavweu,maNHoie
� for the following reason(Secton 7031.5,Bui5ne53 and Pro- AITEP,REPAIR OR ABANDON HOUSE
tes51on5 CodeJ: SEWER OR DISiOSAL SVSTEM ` �
i ���n
❑ I,as owner of the property,or my employees with woges as
iheir sole compenwtion,will da the work and ihe structure �:'E' ° � m � �'
is not inlended or offered for sale($ection 7044,Business
and Pro4essionsCade). �WNER�$ PErmit 5 � � , „?'J�(}
❑I,as owner of the property,am exdusively controtting with AUTHORIZATION TOTA�FEE �
licensed contractors to construcf the projecf(Section 7044, i Hpve ar rHis onTE n coNruqCf wirM rNe HepeiN,uqr,�o WrvrRncroa ro L - � � ''`'�'�'
BU9in255 Onc�PfOf@SSiOr15 COCJeJ. - CONNECi THE ABOVE�ESCRIBfD E%ISTING OWEIUNG TO THE PUBLIC SEWER. , r y�
CONSTRUCTION LENDING AGENCY ���•�u �E
I hereby affirm that there is a construction tending ogency SIGNEDTHIS DAYOF 19,_ �
for ihe performance of Ihe work for which ihis permit is �NEF OR
OWNERS AGENT
issued{Sec.3097,Civ.C.). ,
nooREss
Lender's Name
Landa:s Addreas � �
I ceriify thar I have read this application and stafe that the �
obove information is correct.I agree 10<omply wifh all Co�n1y � . �
ordinances and State lows ragulating Plumbing ond Sewers,
and hereby authorize representatives of ihis County to eNer
upan the ab mentione pr �ty for inspeclion p�rposes.
RCR BY; ��, 7/31/$6
Signature o Permittee Dote � SFE REYERSE FOR EXRIANATORV LANGUAGE
Lt�* - �
� A������++� ��� F� ��Z; . y V,. ._._.. �� � a � . .
INSPfC►DA'S NOT� OWNER$uIL1�ER'13�CIs��WTIO1�3
APPRO�fALS wr� naesroxs s�anaxwc I hereby eHirm thu t em rsempt fmom ehaCantrecta�'s
raw�sew�a .j f
License Lscr£ox the toliowins reavn/SetNos 7Q31.S,
Bwa�os msd Profmfows Codek Awy de9 or cnnwey
.�� � wbicb roqrira o pundi ta mwth*ci, afbM bnpro+ra.
svnc riiNc rrtf3!
darsalab.o►r�qry+b�1cY�ur.M+br'M i�im�e.
Mpiat axluw�"R+e dro re�r�en tEe�p NCR��E Jon�iCL p�rmit to f11r a
�� �� aida�atutos�as t�kr ir A�nwed pwara�t ro tlr�
provi�i�r oj aLe Cmrbtiemh Ihrnzs LTw(Cl�lar 9
(cosuw.�eisg+nlrb S�cAib�7QUDI�DNdsbe 3 0!eb.
B�er awd Frofi�Osr Ca�t1 m`t�ae be is swmpe
��.P°� tbarolrom mwd tbe bwlsfor Nw a�qwJ Asy
� uiolariac oj5s�a 703].f by:ar����?..tnnis
. sip � .. �raot5 srbjwcd ebr�JYl�iaw�t�o a cEufJ aJ�o2�e tbas
/�ue bundrrd do/!m�(f3Q0/w'
�$sc6eo�vnvof°C6e eplp�ffieevr`and
t�e struet�a is aa a�a�Cd�eq�,
/Soc. 71144.Srei�as asd' ' Code�'$r"Cao
arwxarS I.inare I,a�v d�x+aof q�Iy�b a�orusar of
pmprrty wbo brJTdt ar Jr�prows tlimw mrdmbo don
aweb+nank huaw�proofdwf tb�airb ls�pmunnssa
.n+e�mt iot�rd�d or o�imd Jor r,vl��komew tiw
buJJdk�g or impm�rnEt#m!d ass yrm'of
c+oaspletiaa�, t6r aua�a•britd�r u�Jl 6aos ebe lm�d�w
. , of prooirg t6rt bre dld Mot biplld or M�row Jer tbs
lmrymf ojaala.l
�AAt�M�'1"�--•-�.�.�.�--r
B&P.C.fos tWc
Date
Ocvn�
, INSPECTO['S NOiFS . �