HomeMy WebLinkAbout1244A ''��` WORKERS'COMPENSATION DEGLARATION � J
��tl hereby oRirm thot I have a certificote of consent to self O �-f� �
���insure,or a carti(ica�e of Workers'Compensotion Insurance,or ��+�� !S �
acenifledcoy�hereof(Set.3800,�ob�., CE808(REV.B/B1) APPLICATION FOR PERMIT �
r$Vi�b�5139 Company Highlands Insuran� Co. �
❑Certified copy is hereby fumished. SEWER - SEWAGE DISPOSAL . .
�derparl�opy is filad wilh the tounty building inspecrion 4 �O���Y QF,��S�E�� BUILDING AND SAFETY
4U
�,e 8/25/87ApPi;�a„r Amatore Plumbing, In . FOR APPLICANT TO Flll IN CONNECTION DATA
. CERTIfICAOMPENSATION�INSURNCEORKERS• ��u22g16 Estoril Dr. stnnora oevrN
�This section need not be completed if the wo�k involved by�he � Di MANHp�E RfFERENCE � i�R '
� permit is for one bundred dollcn(EIOD)or less.) ���� - i
I certii �hot in the erformance of the work for whith Ihis . �'�sT � trr�oFmNNettior� ��1Hp�
r a c�oss sTPorto Grande and Montefino �, �„� p�, M L.TO i.l. �
permit is isaued,I chall not employ any person in any manner P.C.NO.
so as to become w6jeU to the Worken'com���uo�iow:. ._ . �„presle of Southern Californi �O.�MP.ryp. JOB ND. ���
�"'�17791 Mitchell South TRUNKPERMITNO. RpADPEiMITNO.
� oa�e nPPu�om � �
NOTICE TO APPLICANT: If, afier TOklll 1{lli Cereificofe Of AFFIDRVII WAIVER EASEMEN! RECORD.IN5T4.NO. WiE
9 ��,Y Irvine TE�.No. 660-06
Eaemplion, you should become subjed lo ihe Workers' �'
Compensotion provisions of the Laboi code,you must�forthwirh p[5[x�ior, ioT r+o. t�wr.pt st.wioewnic �
�ply wi�h such provisions or lhis permi�shall be deemed .
ItBd. � &OCK TfA[T STAiE ENCROACHMFNT
UCENSED CONTRACTORS DECUIRATION. � r�o.o�&0�5. �pMiT N°' .
I hereby affirm thot I am litensed under provisionz of Chap�er �����T �W��or
9(commencing wilh Section 7000)of Division 3 of�the Bust•� p�lip�g �.'OIIdOS aARCa�s I
. ness and Professions Code,and my licenae is in full force and j
effea. cartw�croa Amatore Plumbin IIIC• �ONNFCTION CHAGGE FEE �
LicenseNum6er 355068i;�.�cia„ C-36 127 W. State St. - RFIMBURSEA1ENTffE d �
Con�l�tore Pllll[Ib1�� IIIC. 8�25�87 ��ss DISiRICE Np. G1tOUv nuP PRpCE55E0 BY V
a ' Tc�.r+o. — eK rc Z �
❑Iamexemptunder5et. ofiheL.A.Co. I�iC�ENypp, 3SSOGS 0.A55 C-36 lD �� � � Q
aon �
N�. DESCRIPfION OF WORK FEE '
PlumbingCodeand/or5ec. � of�he ' piN,yi ��
I/OVSESEWERCOI�INECTIN(�:p.., DATE VALIDATION � �
B.8 R Code for the following reoson 6 wx'c s�'^'ER 1�.0� ea 1.0 00 �� d �.
MK TANK.SEEYAGE%7 OR f�NA� � �
fli5 AND/OR ORAINFlEI� .
DOtB 1tlU5E SEINFY CONNFCTING f0 B� �1
' VRIVATE D Y 7 M i
� Signof�ro ' ca+Ma noarqniµgtp�.qt � .
OWNER•BUILDER DECIARATION '�K To�oux sewca
OVERFIOW$EEP�GE FIT.DRAINfI�ID '' ���j A I
I he�e6y oNirm�hol I am ezempt from the Contractor's litense euiv.,cessnooi,o,erweu.,wwNqe
Law for the foliowing reason(Setton 7031.5,Buisness and Ro- uteR,c[v��o qt�wnboni�ous� . . . � •
fesslons Co[�e): SFWFM OR o�5PO5AL SrSTEM �Y+ • • • � 0
�i as owner of tne property,or my amployaes wim woges as j
thair sole compenwlion,will do the work and ihe slruUure ( • � � 2,5 Q �
� is nol inlended or oRered for sale(Section 70M,Buslness � � � '�,
and Professbns Code). OWNER'S Permif =
❑I,os owner of�he properry,am e�clusively tonvec�ing w�th AUTHORIZATION TOTAL FEE 112 rj0 'J � i '� � � 7 5��
licensed confractors ro construct the projact(SeUion 70d/� t HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CO+dTRA�TOR 10 � �f�J� �8 7 �
Busineu and Professions Code). coraNecr T�neovc oescaie¢o exisnivc owewrae To rr�vueuc SewcR. �
CONSTRUCTION LENDING AGENCY � , .
I here6y offirm thae there is a conslruction lending agency � SIGNEDTHIS DAYOF 19_
for the parformance oi the wo�k for which this permit is °�R� �
pWNERS AGENT
iSSVBd($BC.�7,CIV.�.�. . �
Lender's Name A�E55 �
landar's Address � �
I terlify thaf I have read fhis opplimtion and stote that 1he -
obove infammion Is�correc�.I agree ro comply with oll Counry -
o�dinonces and Slafe laws ragulating Plumbing ond Sewers, � � . �
and hereby ulhorize repr ta�ives of t is Couny lo enter ' � i
upon Ih ve- ntione operty for' spacfion purposes. � � _ - �
- I
Signatore f erm tee Date SEE REVERSE FOR EXPIANAiORY LANGUAGF �
-- --------"_----
. . . �� Dpo mD �1 DK,` CO �
o� yO �m �j �Y 61-�i C �
� _� �Z m 21
�,9 $y Oyy�D OF pV x '�
- ' ❑! O$ V� � Z� �[^ ,G ^"3
. . f1 CC �n �9 Op O
m Z m� <P O Oo F� C
S A
. .._ ' iO�� ;O � V �
�
U � •
�
� D
� ' ' �
N
0 ij
�
N
� N
• �
z
� . �
C
F
- Z
N
� �
w�
, ' �
0
A
" N
' �
. . N
. , ,..� _-a,Rn�w=-�� �r _
. . � ��£,c �� z� i ^ R ❑e ° � � �1 � ° 6c �3'� ry O.
` � �� � ;, r �'s�3 � � g`� - " � R "�
b� R =�
� . . , � � . � QS ~ �� i � i N�.i� c ���� c ti i c'�"�C a's-� C'.t. . . �
d Y w �. �.. �� �.o^ + �oc _ c �.H 'a �.�p [ £ �, �, -
� R . � � � :.a �.c 3 i.F r'r� ff • '`,= aot�: � ` � � �
'I . . 'C _ R . • Z"x, n O n t�t�, e � �w. M f. x .
. . ' �.. . �' " . � '� C� R •.I'a O� ��V'L W`r•'� �`� �O'���'y' M1�.A'� � . � .
,. . . C `e w'�O Y�+ P A �'��' • `CC � V��e C'�. ,
,� . � t * � ^ ti s 4 n n- w �"
� . ' ' � ' . � •n. A: � C�4 F'4 N ^�'w�£ � R i .M.�Q 7 3 �'^,� V
C �
. . . ' . . . � ' G �R �� ; � 4 n�� MC ��"N..R..� P;a .. L C .
. . . . � �, } 'k'� �C' �C .7 � w '� � R �', , -
. . . . . . � N .R o-y ;��33 F �'+L ` . 1 � C - lt C C�C M � .
i . . ' . . M � . w � .. * fl.� `C 4 C " $.'e S€ �c i^�~;Y c �� �' , .
� . . . � . ' � . .t0 ���\�< <�� � b = ' FC �-X'' n � `n�' .v, .
� �, g' • C � � � .., C�
�� . `o., e.�., ' M c� �� c � � s,� � �� �
�. - . •ry� �D ^ v�� z'.�4 ;.�a`� '�� �.a-�,.^.�e �E'' 9:
I � " . ' ' ' .' . , e i'" � w rt � �L 0.otr C7 ,p 1y � . �:G �' � �.
1 ~�- n ��L C"" t Yi'w w 'r t � �.Z.^ R � .
i. • - . " a��Q's c nc c :a a ' � � � ° i4 S.
b'� � c :..��� c n "':
a � a �.�.n e �.r c .c :,� '° �-..c ^ w c a ^ O
C � ^ � ~b ~ � n
, . _. . . . � , . � � a n'3` e �C �c "�n� c n c• "'n.. � C � e c^ Z - - .
1'' . . � w � C E � � m� a �`� c��� � �� �
' . 1 �� , A � �j �� {3 S'b A V, R n =° A t� � u+
, � . . . .w\ " tY�O O�L• � { r." � �
i. '
i
�