HomeMy WebLinkAbout0964A 1166A (5) N+ORKERS'{OMPENSATION DECLARATION . � - ��
I hereby affirm thm I have a cerfifim�e of consem to self ��?o6w 3�e� . '.T„- . , -- � - - � � � �
� insurc�orncerrifrmM�of-Wwkera<fom nsationlnsuronce,or �6°°r�a���.. � ,�y w' :.,
pe . _- . c�eoe. ... �` � .�,� � JS
�.
-.. .._ ...__. _ .
a ce�tified copy thereof{Sec.38p`p La�bfC,) F' � �.AR.P�.�A�'ftON F4R�PERMIT�� � ���� � - � �
PolicyNo. CompanyJ�'�l� �Vl��__ C�is �.7 � g �c Cp
C]Eert'rfied�<opy�s-hereby 4umished.--.- . . SCW�q -�S AGE DlSPOSAt . . _
___. ...__. ,�. .�,.� _ � R . �:t-..
��y � � �� _.
'R �t3UNT�"OF'L,S A�1�E4E� ri , 6UILDING AND SAFE7Y
pp Certified copy�e(iled with the-county boilding inspecfion � �. - . . .. .
'� �deponmeni. �/� � � '
� . . . < '� '� ?
Date�1-��S_APPlicand_y�1"�1Nc��MSf�Zi� , t:�; ��:FC��AP�PLICANT TO Plll IN ��`f.S 3 CONNECTION DATA
CER�IFiCATE OF EXEMPTION FROM W�RKERS' �� O � STATip+ � �-g � o�viM
COMPENSATION INSURANCE Baooa�ss
(This section naed nm be complefad if the work involved by the � MANNpIE REFERENCE � UiVER
permil is for one hundred dollars($100)or less.) LOCAUTY �pwEg
I cerfify rhar in fhe performance of rhe work for which fhis ��usr. �o�coNrxcri°ri IENGTHFBOM
ermif is issued,I shall not em lo an � +"� cuRa a.t- M.i,ro P.
P P Y Y Persan in any monner v.c.No. Cs�
so as fo bemme subject to the Workers'Compensaiion�aws. pWNER tj" � CO.IMV,ND. JOB NO. 7
�'�� iRUNKGERMITNO. ROADPERMITNO.
Daie Applicant nookess
NOTICE TO APPLICANT: If, after makin ihis �erti{iCOfe Df /7 .4FF�OAv1T WANER EASEMENT REGORD.INSTR.NO. DA1E
9 aTv h� *e�.r+o. c�
Exemption, you shoutd bemme su6ject to the Workers' �A�
Compensofion provisions af the Labor mde,you must forthwith pesc:vivrpw irn no. Nwr,oR 5�.wroftmn�
cvmply with s�ch provisions or tfiis permit shali be deemed
revoked. siOCK TRAR 51AiE RORCNMENT
LICENSED CONTRACTORS DECIARATION � nio.oc si�cs, vrumrt
size oF ior riow ow�or
I hereby affirm that i om licensed under provisions of Chopier .
9(commencing with Sectfon 7000)of Division 3 of the Bosi- B i�toiNGs ii � !-r CNaaGEs
ness and Professions Code,and my(icense is�n/oil force and
CIfECt. w' 'CONNECTION CMARGE FEf /_
�3�2)�Li[.CIO55�_ qppRE55 T� �'V �S � C+ Q SG M �
liceoseNumbe .O. p` , � 3(�(/' }
�/,���/����� t- G O p
Coniracto�SOW`67'�i�.•31t�s Dole �-3—D�_ cm.C ,�� '�� �'�yl� oistRiCiNO. GkOuv v PROCEsSEOBv (J
� Bk vG Z
3 ���-,�--• a
❑I om exemp�undar Sec. of the L.A.Co. uCeNsr ao.5 cuss �
NO. DESCRIPTION OF WORK FEE V
P1um6ingCodea�d/or5x. ofthe ���A� �\,1�'�it� VALIDATION W
HOUSE SEWER GONNECfING TO � DAT{ � A d
B.8 P.Code for the following reason Pueuc Sewea U �r' �
SFiTIC TANK,SEFGAGE PIT Ofl
PITS ANO.'OA�RAINFIEtO fiNAt � 2
° rious�sEwEa cor,rxcnr,c ro B� i� #a�+M��Q
`` PRIVATf DISa05Al SYSTEM
Signat�re 1�• ' CONNECT ADDITIONAL 9t�G OR n f)•C a
W R-BUILD �ECIARATION W�K TO HOIJSE$£MA � Y���i u
py[RF�pW$[EVAGE PIT,ORAINFIELD
I hereby affi�m�hat I am ezemp�from the Coniracior's License exrru.,cEssaeo�,oavw[tt.Manrriae y r2 7.5 �
Law for the following reoson(SC[tOn 7O31.S,BUi9f1C35�Ild PIo- AITER,REPAIR OR ABANDDN HOl15E A �� Q
fessione Code): sewea oa nisPasn�srsrem
❑1,as owner of the property,or my employees wifh wages ps ��.(�$�'8 9
the'rr so�e compensation,wilt do ihe work and the siructure
is not infended o�offered for sale(Section 7044,8vsinass
and Professions Code). OWNER'S Permif E (`�
❑I,as owner of the property,am ezdusively contrac�ing with AUTHORIZATION TOTAL FEE � �Q� �
licensed convaciors to construct the project(Sec�ion 7044, i HAVE AT TNIS DATE A CONTRACT WITH THE HEREIfr NAMFD CONTR C70R TO �� \\� �(�
BUSIlIC55 Of1d PfOfQ5510f13 CO[�0�. CONNECT THE ABOVE OE�RBED EXISf�NG OWELUNG TO iHE PUBLIC SEWER. �B � V _/�
CONSTRUCTION LENDING AGENCY .O� � �Oi � p�
I hereby affirm ihat ihere is o consiruction lending ogency SIGNEDTHIS D AYOf h, 19� �1 �
OWNER OR ,�(� l0
for ihe performance of the work for which this permit is OWNERSAGENi V' �
issved�Sec.3097, iv.C.). (n�/
Lender's Name !Dof ��� p � " �
Lender's Address � h � �a
1 cerfify that I hove reod this applimfion and sfale lhat the
above infor tion is correcf.I agree to comply with all Coonty ,
ordinance nd State laws regulofing Plumbing and$ewers,
and her orize pres tatives this County to enter
upon a e-me ned operty inspection purposes.
' ���,/!7f'�'
Signofure of Permit ee �afe SEE REYERSE fOR fXPIANATORY LAMGUAGE
Z
iF��� �� �f§'� v� o$ �$
' � 9 T ZQZ, �p V A�y �:�i pG
. �� OZ Qa C7Z � iF "Q
� Ct1 rJ � . �n 2n^' T FY?va� s�i 5^�� �
. ' . ' . �� v � . � �1m C9 Np � �m OO 2 �
�� �� m��Y,n m �� F O
c. � .L; cv � �� . �
(�y�j ro �
7 � � • N��� ND A p� r
,�'> � . _ . $q� �„ � �,
,� • • ' N �
_. x% �
� ,. � $
�
� �
d ' _
tlN ' �
� �
�7 . �
� � N
N
� �
�
m
�
�
I �
� I i
�
�
I
1
�
4 '
� 4 �
` I �
i I, • � .'.
� � �. ^r 1 2.
; � � , i � � � ; o
� ', , ' ;� � ; i � � �
� i � 1 E
� i ; � � �, � .� _ � 1 �
� i �; � � � � � � , � �
` � ,, � '� � i � � � , ' I
� .
� � � a � � � ` � i
F 1�, � � , , �;, . � ; ` , . •
. � � � �� ` ! ,� t ' 1 "
� : : . � , � . r
� � I � � M N C C�r"1� � ��� ��$'H
� I a,aNvKHa' e � o��.� °� ° o .�J,'�n � �
x.`"tl,� � � 7b�,� ���.g.�,�.A ���-`°a;a ��° C �
_ � ~ Q ���� �� r�s`O� v' A. ,�, e '.� � �.�" ��{y R Q� .�+. �+
� w� (L� � °° �•o•� •$ r;� s a��a �,oq.�.� � y �""`^M ;cs
� � � ��.oG � y mq b�,,o d tu�.°� �y ,10^,�'yb§�»m a Q p�w� k3?
� � ,'.A�',.F�4`°ap,� � �t+i��M �� � c.A��pb � m ^,o,••. r°
p � a o � o'i`w�a Q,-� �� � � tt f.?.� � � m d
~ `� `° � m '�RT O � � p a Vs•�W�•o w �„n ,,, w i O f3 C�1
' �. .�r. �'A m`Y p � a.px .ro�. N o L ��`�' °p� p`tis.� o n S�i �
� v' L�. �R.� � ° �$ p'G'„��.Q, .f:.,�-+ �'•.,,^ n °�� '� d
� a � ^ � �y "a w o • �.�z a�s°a,c'"`:$ � °x�-"b CL7
f~Q ,� w �i'il'0.b `.R O Q M�,n !� � •,,�,.C t"A T v+ R '� (7
C/3 � '�.' N .�.�°° ^ .� � �. ��..I'i'� �' •c `ti.,,�'n .i
x r"
. �Ns. A, Q" p O' �G C �o e�'C+ p O O h�,
' ,��j . � , fi K A ?�t �•ec S� .�...b� '`'^a C.�'�'r Y n 5 1�
.� ��. c �tL� �� o w.CY'i C���t0 � ti.�.� "'T '� .
ti� �, m
w p a.��� C C�O C �t � „`�.G C a w.y� `'� O � .
• �y,n ,r T,�a io o „s+ '»M � „y.
' �,� o c.,.��s^.�� � n ` � y y'v �.�T �;d o w 3 n `J" �
.�:. r wti oW
. . e � �m n � � c S�� �b � � o R�,�,C r�o x w Q
� - t¢ e! �,.� N . };+ � �O IG�"fi ti�� �r � ~ri
�I ' `n�l0 Y w� � le � C LT`.� '��G! ' W p � W�N b. .
� � ,ay A o�e o � �,� r�w
� � ' ��`a�' ��.x cs.
i �
��,l_`�._..-.