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HomeMy WebLinkAbout1245A �� ����.,��. WORKERS'COMVENSATION DECIARATION � - - � ' eby offirm that I hove a certifita�e o(toesent to sel( ' `/ L S'� -�'?r�;�e,or a cer�ificate of Workeri Compensotion Inwronte,or � �d"6'io . � ������h�Haie�dsbInsurance CO. �EB08(RFV1/871 APPLICATION FOR PERMIT ❑Cerlified copy is hereby fu�nished. Trac+ �as 3� � SEWER • SEWAGE DISPOSAL � ��ertif�ed�opY�+r�tsa wirh the county bu�id�ng��,P��,;o� Units 395,396,39�,��,���5�►�I�ELES BUILDING AND SAFETY � �,� ���/87A�i�Auyatore Plumbing, Inc. FpR APPLICANT TO Flll IN CONNECTION DATA CERTIFICATf OF EXEMMION FROM WORKERS' euna� STATION " DFPTN COMPFNSATION INSURANCE noar�ss (This section need not be campleied if the work involved by the �p[ALI7Y Diamond Bar hV.N1fOLE RFFFRENCE ��Q � � permit is fa one hundred doilars(SI00)or less.) ' � R � �^�5i Porto Grande and Montefino T�����T�� ��+cT��� I certify that in the performance of the work for whith this' citO555T. v. CURs P.l. M.�,TOP.L. permit is issued,I sholl not employ ony person in any monner so os to become subjecr to the Workers'Compensai�on iow5. Presle Of Southern Cali f. °-��`'1O� + OWNER Y [O.IMV,Np. lpg Pq. Date Applicont n"""oo�acss 17791 M1tChe11 SOIIth TRur+Kv�eMirr.n. rso�ovtw,�rtNo. NOTICE TO AVMICANT: H, oHer mokin �his Certifica�e or - Irvine 660-0660 A�F�DAVII w�iv[rt e.�se�r�n RECpRD.INSTR.NO. DAIE � � 9 [rtr r[t.r�o. Exemption, you should bacame subject fo the Workers' �c�i Compenwlion provisions ai ihe Labor code,you musf forthwith p¢5�q�vrroN �oin+0. Hwr,pR57.wiDEMHG r" ��ply with such provisions or fhis permi�shall be deemed �ked. - �ocK TiACT � SiATE ENC009ClMNNI ' ' UCENSED CONTRACTORS DECIARATION w,a�ocs. PFR""""�. SIZEOftOf � ' NOWONLOT I hereby affirm that I am liceneed under provisions of Chapter ��� ' 9(Commencing with$eUion 7000)of Division 3 of the Busi• euimnacs COIICIOS CNA¢GES ness and Professions Code,ond my license is in full force and , - affect. ��TRpROR Amatore Plumbing, II1C. CONNECTiONfHA4GEFfE ' L�censeNumber 355068 ���,Clas: C-36 A�� 127 W S a RE�MBURSEMFNTffE � Amatore Plumbi�c�, Inc. 8 25/87 , �'` j Controcro. �iT� Ontario,E,.No. 986-5878 orsrwicrno. ccouo M�v PRO[FSSEDBr a. i /� BK 0( O I ❑lame■emptunderSec. of�heL.A.Co. iIc"ENscrvo rJS ���u C-3 rO IK I m0.�O11'e �ot � NO. DE$�RIVTIONOFWORK FFE � PlumbiqgCodeand/orSec. ofthe ����q��� To DATF� O weucsev,4w � VALIDATION V B.B P.Code for rhe follewing reaton PTI TANK,SffVAG(PIT pR W � VITSAND/ORD4AINfIEID fINAI . N Dd�e MOUSE SFWER CONIJECTING 10 BY Z . AIN�TE DI v 1 M � Siqnature (.pfJNECT AOOITIpNA�&DG.OR � - OWNER•BUILDER DECIARATION �+'`ro"°�s�s�°'ER pVFVfIOW SEEOP(�F7.OR�MFIELD :�� �n G^ I he�eby aHirm that I am exempt from Ihe Con�roc�or's License FxTN..�ESSR70L.DRYvIEIL,MANHOIE y,��� � LOW fOf/FI��OIIOWIl19 IBOSO��$BC�011 JD3I.S,BUISI1B54 Ofld Pf0- ALTFR,PFPAiR OR ABANDOtJ 11pU5E � - . ' �ESSIOlIS COCIl�: SFM/ER OR Dt$POSAL WS1FM . ;�o � • • � o M n I oe pwn.r nf 1he ! �� tn r. '� r: - pro;e!y,o!n?y?mp_yee!wi h�va�es as � � ��• � � 2 Jr� �:heir sole compensotion,will do ihe work ond the strvtture � --�is no1 intended or offered for sole(Sec�ion 70d�,Bvsiness Permit t 10 50 and Professions Code). OWNER'S • ° � � 2 5 Q� ❑1,os owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE 0�3� �8,� Ii[BnSBd tOn11ON0�5 f0 COnSkud�h!PfO�eCi($ettlon 70dA, 1 NAVE AT THiS OAT(A CON(RA�1 WIiH iME MEYEIN NAMED CONiRACip4 i0 Business and Professions Code). conirvect rH¢naove oescaie[o ezrsnn�ow[wrac To rwc avxK stv.ta. • : � CONSTRUCiFON LENDING AGENCY � , � � i I hereby oHirm thol ihere is a consfroctian lending ogency SIGNEDTHIS DAYOF� Iq_ � for the performonce of Ihe work for which fhis permit is �R� OWNE45 AGEM ISSUGd(�C.����IV.�.�. . ADDGE55 lendar's Nome . lender's Addreas � � I certify thot I fiave read this opplim�lon and state thot the �1 above information is correct.I agree to comply with oll Counly � ordinantes and Stata laws regulating�lumbing and$ewer5, and hereby ulhorize repre lotives of this County�o enter � upon the ove entioned r perty for inspection purpases. $ignol�re of ermif e Do�e fEE REVERSE FOII E%►LANATORY LANGUAGE ' {�� ..-� _ • _ . _attu...._ ' . ._/ _ - - - . - - - - -- . . � -- . . ._ .. . . . .. . .. ,. � r:.� �n �m a qn , � -� � � � . : ; ' � � ' � o�i a'i, ,:�_ ., 7� �n K . . . � � � T�� �.. i, ��� t�: � - , . i : �� . rx. .� � 4'.' �z . r j S'` .. � ;!r �y; c� , _ i i � Z y c?�" - o r_ j, , - . I +� � i 3 ` ': �� D' }'< .., . . .. . � � .. . , . ; i i ! ._:,; c.� `�' i i` 4=; ZJ ' i i � n?• .' I'? � ^ �'': � . ' � " '. , . � ^D <ii ��� � ;_ ', ; �---: � � N :;: . _ --� . +i , _. , �� `' ,� N' _. . N. � �._ _ i . .. i .I i - � . , n� , . . , , ". , . ' ... �', j. . ' ... 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