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HomeMy WebLinkAbout1251A (6) ����-`„ WORKERS'COMPENSATION DECLARATION . � �� I hereby offirm rhor I hove o certifieole oi cm►enf lo sel( }1 ��ineore,or a te�tificote of Workers'Compenso�ion Insurance,or ]6A617D ' II rroT�.T ll atenifie�����.���,p INSV+�L,CE COCE809�RE�.1/831 qpp��CATION FOR PERMIT � - Volicy No. Company ❑Cenified copy is hereby f�rnished. 1 f 4et 4a5 33� SEWER - SEWAGE DISPOSAL [��e�rptoified copy is fued wlrh rhe county buildinq inspecron UIIitS 428�42 9����TY40�F2L05 ANGELES � BUILDING AND SAFETY ome OS 25nr.s' � " ' / / Applicane�►atore Plumbinq, Inc FOR APPLICANT TO FiLI IN CONNECTION DATA CERTIFICATE Of EXEMCTION FROM WORKERS' ����j 2 1 E COMPENSATION INSURANCE srarior� otrrw (This eect�on need nor be compleied if the work involved by tbe ,«,,,,,,.Diamond Bar ��+Hae x[rEe�rdcc � , uwtQ � perm�t�s tor or+e hund�ed dollars(f100)or less.) � I certify ihat in the performance of the work for whtch ihis CRpusg�, POTtO Grande and Montefino Y rYr�o��orw�ERwr+ �^�TH�yp�' CURE P.L M.L TO V.L. permi�is issued,I sholl not emplay any person in any manner r.c.r+o. ' so az to become subject lo the Workers'Companwiion Laws. o�q Presley .of Southern Calif.� co.iMo,rq. �oe wo. . Do�e Applicpnt �DDRE55 17791 Mitchel TWVNKPERMITNO. ROADPFRMITNO. NOTICE TO APPLICANT: If� O�f9� mokin �hi3 Certificote Of Irvine AFFiDAVIf WAi�R FASFMENT RECOfID.INSTR.NO. WiE g �iTM ,F,.,�.660-0660 Ezemprion, you should 6ecome subjecr to the Workeri iE�� � Compensation prov�s�on:of�he Labor code,you musf forihwi�h p($[P�pTIpN , lOTNO. ' �pyy.�q$T.WIDENING - ply wi�h suth provisions or this permit sholl be deemed " �k�, &OCK T4.4Cf STAIE ENCROACHMENT . - "'� LiCENSED CONTRACTORS DECLARATION rq.a e�p�s v�oMiT uo. i SRE OF LOT NOW pN LOT I here6y aifirm fhot I om litensed vnder provisions of Chapler 9(commancing with SeUion 7000)of Divislon 3 of the Bosi- a iui i�s COIId a�rtcl5 � ness and Professions Code,and my license is in full force ond - effetl. - - �pri1RARpR Amatore Plumbing, Inc. CONnECTiONl1�aRGEi(E . Lice�seN�mber 355068 �iC.��O55 C-36 A�E� l'1 R[IMBUFYMFNTfEE - � i o�,���re Plumbing�,QInc. 8/25/87 14 o�sniara. wwv .w.v vcacEsseoev a. aTv OIItdLiO Tf,.�o. 986-5878 aK nc 1 v ❑Iam�erempr�nderSec. � oftheL.A.Co. ��EN�� SSOGB ��AyS C-36 (� a—� �Q`a�,e .� �. DESCRIPTION OF WORK ' iEE PlumbingCodeond/or5ec. of�he FINA� VALIDAT�ON O 4 MOUSESEWERCONNFR�NGTO 17.00 ea 68. 00 °A� ���� �i W&IC SEWER B.6 P.Code for the following reason WIC TiNK,SEE��GE GI7 OR N � PITS 4ND/OR DFAINFIELO FINAt DOIe MOUSE SFWER CONNFCiING TO BY C Z PRIVAiE D�5105A YSTEM $i9nO�UlG CbNNFCf PWITIpI.�qL&DG.OR ' . � � �. OWNER-BUIIDER DECLARATION womc To`aus[s�wex OYFRF:OW SEEPA P:.DRn:NiIEtD I heroby offirm thot I om eRempt from fhe Controtlor's Litense � [xrN.,tcssoopi,pwrwiu,nnnNwae o� c� 2�3� A ' Low for the iollowing reason(Secion 7031.5,Buisness ond Pro- urta.aevniR oa ne►nooni�aus� 0 � fessionsCode�: . sewERoao�scos�tsvs�M - u• • • • � � , I m owner ef th•p•oFe�y,o•,,;y e,•+.ptoysas w�!h wa9es ae � I � •7 Q J�O i heir sole compenwtion,will do the work ond the shuct�re '" _ is no�intended or offared for sole(Section 7014,Business � o�d a�ota::�o�:cod��. OWNER'S Permit s 10 50' � • �7 8 5 G� ❑I,os owner of the p�operry,om exclusi�ely conrrocting witb AUTHORIZATION TOTAL FEE � 0 a 3� •.8 7 �IClIIfE'd[OfI�fOC10�5 f0 tOtISfIUC�1�1C pf0�2C�($Ef1i011�DI4, ' I H�VE AT THIS DATE A CON74AC7 WITH fHE HFREIN NAMED CONTR�CTOR 10 � Bt151l1B55 011d P�DICSSiDlIS COdC�. C0�1NEC1 TME ABpVE pE$CRIBED E%ISiING DWFIIIFI�i TO TME%1Bf�C YwFR. ' CONSTRUCTION IENDING AGENCY ► • - I bereby aNirm that Ihere is a conslruUion Iending ogenty SIGNEDTHIS DAYOF 19_ , for the performonce o( �ha work for which this pe.mi� is �`""ER� OWNERS AGFNT Iss�ed(Sec.3097,Civ.C.). aooeEu tender's Nama lender's Addreu I tertify ihat I have read this applitalion ond state Ihat Ihe . . , above Informotion is correct.I agroe to comply wilh all Counfy �, ordinances ond Sroie laws requlating Plumbing and Sewers, � ' . � and hereby ou� ize presen s of this Coonly lo enler ' upan the�v -menti ed pr� e� for inspection purposes. � .51 lure of P r tl Oole SEF REVERSE�ORlX�IANATOM I�NGUA6E ' Louis J Arr.wture • , . . � . . . . . . ;)�. r� Y,, C(1 m i . '. . . . , � .. .. � �; ��C7 D T� y(7 �f� �'•� S . � I j ' ' . � C n� .C) x T �i�� C� i' � . .. . . �i � . . �I , i'�• o: '� ^1 i T, � . . . � , . . .. ?, Trl 2_ �r-� v .� . . .�to Si� (f'v \J T," ��y � . . �. � �.... . ' , � fl c.� i�c� ^�(T ��) ' � , - . �_'•. � • � �_ , r D � •�:, ;� <�., C , " , - . . l . 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