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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. 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