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HomeMy WebLinkAbout1248A (6) WORKERS'COMVENSATION DECLARATION ' � , rr��� I hereby offirm �hot I hove o certificote of ctmsenr ro sell � � x n ��.insure,or o certificote of Workers'Compenso�ion Insurante,or �n�aaao /) ��I a ce��iiied to thereof Sx.3800,tab C.J CE BOB�NEV.1187� V ' �J PolityNo. ��CGO���„Y �Highland ,�nsuran�e - APPLICATION FOR PERMIT .. �c,„;,;�a�,Py;,h„�by f�,�;,,,�a. p SEWER - SEWAGE DISPOSAL-� � [��er�ified copy is filed wirh the caunty buiiding inspection (JriltS 407,408�4�9UI�TlY�F�L�S�I�'s�LES BUILDINGAND SAFETY deparlment � Date $�25 Appiicant �atore Plumbing FOR APPLICANT TO Fill IN CONNECTION DATA � . CERTIFICAOMPENSATION INSURAN EORNERS' ���u 22920 ESt0r11 DT. FATION DEPTH (This sectton need not be completed if the work invoived by�he i�,iin• D1dIri0IId Bd� �N�LE RE�ERFNCE Up°�R � permit is fw one hundred dollort(SI00)or less.) r�c,�sr rrv�acav�crroN IE/�CTNf0.0M I certify�ha� in the performanca o(the work for which�his �pugT, POr�O Grande and Montefino y. �� p,i. M.i.tov.�. permit is iss�ed,1 sholl nof employ any penon in ony manner p�� � so os�o become subjec�to�he Workeri Compenwr�on tows. owr�R Presle of Southern Calif co.v.v.r�o. �oe r�o. I � ��� � TRUNK iERMiT NO. ROA�PERMIT W. Da�e Applicanl aoo�ss NOTICE TO APPUCANT: If, after mokin this Certifimte of PffID4V17 wnrv[e EASEMEN7 cecato.iwsra,r+o. wTt 9 aT� Irvine Te�.��o. 660-0660 Ezemption, you should become sub�ect to �he Wwkers' iE�i Compensation provisions of the Lobor code,you must forlhwith orxaimiow ior r+0. Hwy,dt ST.wio[Nwc �--+ply with svch provis�ons or rhis permit sFwll be deemed jked. eiocK TRA�T SiATE ENCR0ICHMENT LICENSED CONTRACTORS DECLARATION ND.OF&DGS. VERMIf NO. S�ZE Of lOT NOW pN LOi I hereby affirm thal I am licensed under provisions of Chapler ��� 9(tommencing wi�h Section 7000)of Division 3 of the Busi- BunoinlGS � papGES �ess and Proiessions Code,ond my license is in full force ond • B{fBCI. . . - �pNTRACiOR Amatore Plumbing, Inc. ca�c*��c�•�� litenxNumber 355068 �I[.��OSS C-36 q q ADDRF$$ � a e . RFIMBURYNfNTF[E d ' �a���o��a� Am�tore P1t�lAg� IIIC �/GS/H/ ` DiSTRICTNO. GQOU� �a vrtacesseoer O � aTv Ontario ni.nw. 986-5878 .p BK �c v ❑tamezemptunderSec, oftheL.A.Co. iI�E1��. 3$$OF)H n�u C-36 tb f�'` �q�Of�e O NO. DESCRIPTION OF WORK fEE ' F� Plumbing Code and/or Sec. of the rnuu V ' waic�v"�+cRCO""`R�"�l°7.00,ea 102 00 °ATE VAUDATION �u B.8 P.Code for the following reoson 6 mi TANK,s�Ev�ct vrt ort y Vi75 MJ�iOR pR11NGIflD FINµ Z ��8 IqUSE SEWER CO'M�ECfIAIG 70 BY of1�VAT DI SYSTEM ' . $ignature cor+r+cct�wort�ow,i e�oc.at OWNER-BUILDER DECLARATION `�+K r°�us�s�v''ER OVE4FIOW SEFPAGE PI7.pflAMF1El0 -�-�'1 2 4.8 A I here6y aHirm 1ha1 I am eMempt from ihe Conlroclor's Licanse E%TN..CESSPOOL.DPYW4lL lMN110LE ' . Low for the following reason(Secton 7031.5,Buisneis and Pf0- � 4liER,REPAiR OR FMNDOfa NOuSE n #a � � � � � � SEWER OQ DISYpSAI W51EM } fessions Code]: f o` n I,o�ownar of Ihe properfy,or my employeas with wages as i � i i �v v heir sole tompenwlion,will do the work ond the shutture � ` - is not intended or offerod for wla(SeUion 70�4,Business ° ' � � 2.J��c=i ond Professions Code). OWNER'S Permit s 1.� $0 ❑I,as owner of the property,am exclusively tontracling with AUTHORIZAT�ON TOTAL FEE ����� —8� IICG�SEd CO���OC�O�S 10 CO�S�fUC��FIG PfO�E[I(SCC1i0�7W4, 1 MAVE AT TNIS DATE A CONTRP.�T WIM iME NfRFIN NAMfD CONTRACTOR TO � � B�siness and Professions Code). ca�n+ecr r�neovc ocsca�eco exisr�nq oweu�r+c ro rHc Pu��c sewca. � � � CONSTRUCTION tENDING AGENCY � ' I hereby offirm tho� �here is a cons�ruction lending agency SIGNE�THIS DAYOF � ID_ for ihe performance of the work for which Ihis permit is �NFR04 issoed(Sec.3097.Civ.C.). o��aSAc[Ni . Aooress lender's Name lender's Address � 1 certify that I have read this applicaiion ond sfo�e�hot�he above info�motion is correct.I agree to comply wiih oll Counly ordinances an Stnle laws ragulaling Plumbing nnd Sewers, � � and hereby Ihori:e repre t �ives of this County to en�er � vpon�h ve-m tione � erty for inspecfion purposes. , . � ignoture f G r e Dale SEE REVFRSE FO�E%►LANATOKY IANGUAGE . 1+Uii1 . rimatore � � ' . � . . . ' � '" . ` ,i' . .. . . L D��� z�" C 7 r7.: � o!'1 D!1 �:.-� �' r � ' ' . ^ 7O 1•x• ( A f� C;• f � ' ' . . . ' .. . . . ' : S }�'7 '"�" Cj' D G%�' � _. . . .. , � i y c)'.:, C�7 O I, r' � ' ' ' ' 1 ^ �� O Yn A.tl ' � � . � . � . � i i. i .J�ti f,C j�';'-. 7` £1.� T , • � � ' _' . ''i . . .� ➢ .1 n. 4'C� , � � , . . . �. .__ :.= "a <: 'o cio �l - � . , . - _ j , . . ' • . � n �ii �� .t ' � �� , ' • � __ i r❑ A" 'f ' .I - � ' • _ . . _ � � ' .,I � � v; � ��.: v+ • . n , � � ' � ' . .�' , ` � i� , . � _I_.-_ . . . 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