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HomeMy WebLinkAbout1246A � ~.'S. WORKERS'COMPENSATION DECIARATION - � --7 � � I-fiereby offirm rhal I have o te�tificote of cemsent to sel( `// .�imure,or o tertificaie o/Workeri Compeewtion�nsurance,or ]dA6�70 . �j � a��,��f� ��.3�ereof,(Se. ��abjnsurance co �EB'JB�RFY.I/831 APPLI�ATION FOR PERMIT v` ��� �� O c�.��r��a�orv�S ha.�br��.��■haa. SEWER - SEWAGE DISPOSAL. '�Cerrilied topy is filad wi+h rhe coun�y building iropee��on [jnit5 436,437����Y�F�OS ANGELES BUILOING AND SAFETY Date e��,�,5�$Appl�cant�atore Plumbing, In . . pOR APPLICANT TO Fllt IN � tONNECTION DATA CFRTIFICATE OF EXEMPTION FROM WORKERS' . �,io,� � COMPENSATION INSURANCE �ooRcss ZZ E ril Dr. Sunora o[rtH (ihis secr�on need nor be completed if the work involved 6y the M4N1qtE RFiERENCE VP°ER permi�ii for one h�ndred dollora(5100)or less.) ���'TY Diamond Bar rr "�"RE57 Porto Grande and Montefino T°EOFON"ECiON '�"'�""4O"" - I ceriify�ho�in the performonte of the work for which.this �eossst. v. Cuke v.i. n�.i.tov.�. permit is issuad,I sholl not amploy any person in ony manner - so as�o become subjac�to the Workeri Compenw��on laws. �Q Presley of Southern Calif co.v.v.ra. ioe r o. .. �`�� Mitchell South iRUNKPEQMITN�. ROADPERMITND. Date Appliconf �ooxess NOTICE TO APPUCANT: If, oftar making this Cerfificote of arv IrV1R@ rE�.No. 660-0660 ^FFionvir wniv[R EASEMENT actceo.irsrv.rao. nnn Ezempiion, you should become s�bject to �he Workers' LEG4L Compenwfion provisions of ihe Labor code,yoo musl forthwilh o[scaivripu �arrio. Hwv,qe st.wioetiuie � '�ply wi�h such provisions or this permi�shall be deemed . ,k8d. &OCK iRACT SrRiE ENCROACHMFNT J � LICENSED CONTRACTORS DECLARA710N , r�o.ov�ocs veRmrt ra. s¢e or ior NOW ON LOT I here6y affirm�ha1 I am licensed under provisions oi Chaptar �� 9(commencing with Settian 7000�of Division 3 of Ihe B�si- purtoin�5 O�nRG[5 ness ond Profeesions Code,ond my license ia in full force ond effecf. �rxncroR AIIldtOre Plumbing, Inc. �ONNECT�DNCHARGEFEE _ � LicenseN�mbCr 355068 �;�,Closs C-36 �Eu . tate St. cEiMWRSFMEMffE �, � Amatore Plwmbingda�Inc. S 25 87 . DRLQKfNO. GROVP M.P GYOCFSSEDBY n. � co�����+�� c�r. Ontario m.�o.986-5878 ,K ,� o ❑IomeyemptunderSee. oflhal.A.Co. ��Ngr,p 3SSOGS `�'iA� C-36 . lQ R� � �,,p�� V m NO. pE5[RIPTIONOFWORK RE PlumbingCode ond/or Sec. of the �pv��wea eor+r.�eriwe ro DATE� VALIDATION O �,��cs�,M. 17.00 ea 51 00 � � B.B P.Code for the following�eason 3 i ANK,SEEYA ni oq pw, YITS AN�/pR ppA1NFIELC FINAL N DOte WUSE SFwF4 CONNKtIfvG 70 6Y . Z . oRiv� asvosu v ^ Siynolure coNr+[tt�oo�r�or.�u eioc.ox � OWNER•BUILDER DECLARATION '.�04K Tp Mpp$(5(N4R � OVfR�LOW SEEPPGE W.f.D4A!NF:ELD /� L � I hareby affirm thal I om exempt(rom Ihe Conlractor's Ucense E%IN.,CESSIWI,DRYWELL,hUN1KKE ��� �u v A Law for the follawing reoson(Sedon 7031.5,Bvisness and Pro• .utew,aeaniq oe ne�rioora Hous[ � � fessions Code): s[v.tR at oisvos�i srsreM #• • • • � p ' �I,es awne�ef rhn prnrn,rty,nr my..�,ployo..�y{th wages as �1 � � � • •61,5 0 � ��heir sole compensotion,will do Ihe work ond�he struUura s not iNended or offerod for wle(Sec�lon 7014,Business � ' � � _ � ood vroFes:�o�s codgl. OWNER'S Permit s 10 50 •6 1.5 0:., ❑i,os owner o(�he proper�y,om e:clusively contracting wfth AUTHORIZATION TOiAI FEE 6 50 p�3�-g� I'iCMStfI COnlrp�101S f0 CO�S�fVC�II1B PIOjCCi�SCC�iO�7044, 1 NAVE AT 7H15 OATE A CONiRACI wRH iHE NERFIN fJ�MED CONIRACIOR i0 Busi�ess and Profess�ons Code). toNN[cr rwe neovt otxaie[p¢xrsnr+c ov.4unac ro T�weuc stv.ea. CONSTRUCTION IENDiNG AGENCY , 1 hereby affirm thot lhere is a consiruction lending agenty SIGNEDTHIS DAYOF 19_ ' for the performonce of the work for which Ihis permil is ��ROR . � OwNFRS AGENT ' fesved(Sec.3097.Civ.C.). a�oaess Lender's Name . Lendei s Addre�s " � I certify that I hove read fhis opplication ond sta�e Ihot ihe a6ove informo�ion iz correct.I ogree to comply wiih oll Covnty ' � xdinances ond Stole laws reguloting Plumbing pnd Sewers, . • •nd hereby �th ize repr n�atives of this County to enter �on fhe ve- ntione operty for inspection purposes. Signolureo �m�tfea Do/e SEEREVERSEFO�EXMANATOMIANGUAGE ,0I51ri i j. n,i�... - . . . _ . ' / n•n m . . . . • � � � " � s g "?• ^ 7-�i�. ��% t . . "`,fl Ti1 bx, �.. �fl �=' 2 , .� , � �, � � n c�.,, � ,' `r�L: c D' • . , . �' - Z�i n^ ry +�.. � � - .. . . , . � . ,i .i ; �. : ' ^; r`.; '' t7 i' �t. 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