HomeMy WebLinkAbout1250A `�� WORKERS'COMPENSATION DECL4RATION � �/ �
`eby oNirm thol I have a cartifitate of consenl fo self <�/, �
.�e,or a cerrificote of Workeri Compensotion Insuronce,o� 1e^�'T� � X � �-
����`�«�g���ereof(5�1 .�o�1S Insurance co�E808�RfV.B/Bl) qpp��CAT10N FOR PERMIT �f "
olicy Ro. Compar� 0s
❑Certifiedtopy is herebylurnished. SEWER - SEWAGE DISPOSAL � � .
�Cer�ified topy i:filed wi�h�he coun�y building��sa���o� � Units 423 4���O��gS��I¢�4�$ BUILDING AND SAFETY . .
• i i i
°�p�'3%87 Amatore Plumbing, Inc.
Dote Applican� FOR APPLICANT TO FILL IN CONNECTION DATA .
CERTIFICA7E OF EXFMVTION PROM WORKERS' eunoir� STATIpJ ptvte �
� COMPENSATIONINSURANCE �oat[ss 22925 Estroril D"L. �
(Thia sec�ion nead nol be compleled i(Ihe work involved by tha � ip�piiTy Diamond Bar AUNHp�E REFERENCE uocea �
permil is for one hundrcd dollws�f100)or�ess.) - � �
I terfii �hal in�he__1ormonte of the work for which this �AREST porto Grande and Monte£ino trveof[orJrrtction ��,TH��
Y Y�'• Ca055 ST. Y. CURB v.L. M.L.TO P.L.
permit Is isaued;I shatl nor employ any panon in any manner P.C.NO.
io os to become subject�o the Workeri Compensdtion laws. .. � �R Presley of- Southern Calif �p.��.p�p. � �oe r+o. '
� 'M'��� ZtC L SOUt TRUNKPERMITNO. . RO�DPERMITNO.
De�e APPliconl ���
NOTICE TO APPUCANT: If, after makin 1{Ii3 �erlificole o� AFFIOAVIT WANER EnSEMENT RKORD.iNSTR.NO. DATE '
9 c,rr Irvine t�.No. 660-0660
Exemption, you chould bxome aubjecf lo the Workers' .
Compensaiion p/ovisions of the labor coda;you mus�forthwith �x�� totrro. �
-vnply with auch provi�ions or this permit ahall be daemed �+wv.a sr.x�oeHinic
�kOd. ' -�' ' ' - ' B100: TRACf STATE ENCROnCMMENT .
'LICENSED CONTRACTORS DECLARATION � � �.a��. �R""�T�iO� .
I heroby aHirm that I am Ilcemed under provisions of Chapter srz¢oFtoT ropw oN ipT ,
9(tommenciny wiih Section 7000)of Divislon J of fhe Bosi- � � p���p�g OIL OS ;
w�xc�s
ness and Mofeasiona Code,and my licanse is in full force ond �
effecr. � � � � �p.,ra,�,pa �Qiatore P1UIIIbinq, Ine. ca+r+¢crioricMnac[�e
355068 C-36 r �
Licensq Number Lit. lass . d C .
ADDRE55 REM1BUq5EMFNi FEE d-
AIDdtOTe P ll lllq IIC��7 oisreicT w. c,�+our �v wotesseo er �
Connactor �Dore crcv Ontari0 rE�.No. 986-5878 V
❑Iamexamp�underSec. oftheL.A.Co. L�N�� 3$$OE8 �uu C-36 l(� R� �� � �q�pne O
Plumbtng Code and/or Sea � � of the �� DESCR�VTIIXJ OF WORK r[e ��NA�
NOUSE SEwER CONNKTiNG 70 DATE �•
6 �,,,�K��R 17.00 ea 10 00 �j VALIDATION
B.8 P.Code for ihe(ol lowing reason � SEnT�C i�Nk,SFEa�GE nt On � �r' " N
DITS AND/pR pRqINf1ELD BY A� _.�
Dote ��5[gyy[R CONNKTING ip �-
��� � aw�v� asvosu vsrt.n .
Signature [oNNER MdiiOnwl plpG.pR
OWNER-BUILDER DECIARATION �F 7O���'�'E°
OVERFLOW SfEV1,GE NT.dl111NFIElD '
I hereby affirm that I am exempt hom the CoNractor's License E%TN.,CFSSPOOI,DNYwEtL,MANHOLE �� G��A
law tor the following reason(Sec�on 7031.5,Buicoess and Pro- uh¢,uevew oa,.e�Hooni Hous� �-
fessions Code): sewEv oa oisa�s�t srSteM .'��� , +�� � • -• � 0 .
^ i
'J I,as owner of ihe prooerly,er mv emoloywes with wogws os � i
�.,_�thair sob compensofion,will do ihe work a�d rhe strocture " �� ° � 1 2,J`� �
is not intended or offered 1or wle(Saction 70d4,6usineu permit S 1�, 50 ° a � � 2 Jr('j czi I
and Professions Code). OWNER'S +
❑I,os ownar of the property,om exdusively mmmc�ing wirh AUTHORIZATION TOTAL PEE ��3� ;.8 7 �
licensed coNractors lo conslruct the project(Section 76d4, i ru,vE nt nus w.re n conrtanct wiTH r�HcutiN Hnm[o cavTanc�oa To �
Busineu and Professions Code). -- cor+r+ett TNe neove pescaieEo cxrsnnic nweuinie ro tNe vueuc sEwFa. � (
CONSTRUCTION LENOING AGENCY ,
I haraby affirm thal the�e is a conslrucfion lending ogenty � � �GNEDTHIS DAYOF 19_ � �
for �he performance of fhe work for which this permit is �R� � �
OWNENS AGEM �
, IfSUEd($!C.���CIV.C.�. '"
. ADDRE55 �� i
-. Lender's Nome
�Lender's Address . '
1 cer�ify�hat I have read this applicalion and srote�hot the � � � �
,obove information is corrett.I agroe to comply wiih all Covnty . .
�ordinancas a d S1ote lows ragolating Plumbing and Sewers, � � � ' �
ond hereby u�horize repre lalives of�his Co�nty to enter
�upon fh ove-m e pr perty for in�ettion purposev � . - �
Signofure P itlee Dote . . SEE REVERSE FOR EXMANATORY LANGUACE �
. ...�.iLL� _ . r..�,a... _ . - ,
"�--''✓
___—��_"""�.--
_ __ . � G m
_ , , u �¢ �� � °�� � �y
.-" _ .r+� �� ZO qA � A� Y� y` !'
G�
p ^' 'Q
��� f . , . . 1� Oz � �T p� � �
��x� '^'- O ?�r �� 4 "'
.�� , �n�c$� T: o-g� O
. � � 4:.c, 4 � o� : �
' M z �v �;� 1 V. �
�
..1� . �N p� � � .
O ;
. � O
', _ �
�
1. ` o
I �,
,�i � , 1
� �
' � , A
, N '�'
�O _ G�
� a �
i, N . G
, - �
�, _
� . Z
�� , N
� V
� , T
', - a
0
I . �+
.� O
�n
�� '
, ,
' `
` .
��
1
i
�
a r ,
� �'o �.°..�"a.t rt S
• . �_ �.jr� 3 c i � c c-i e� n ' �
R
' " �c �"y � n R �R 3'�'' $ 3 �.N� �. . � r'� �.
� � c ^ � c �. ^ + a c a-w . �
. , :�'�,c s w o-^e � '�s L ;� � a ?, i, r � �£ � �
, . , . .a b.r �y � M-.!G v a ` ` L �. . w M� y ,.. .
- � ..+ ., c,� -C� G.R t a� •�.,= . Y, „�,�~, C . a", .. .
� p C 'X `t �P n v `g Ot
' O � � r � :.�a' -•�„� t-.s.� �c..,r��ia� E v i �"� L "c c� C
C� '' �..oc s � — . e''d� " � 4.'C ^ � R �' w� a; '""
�. . � � � � ro i< L p. , w �a �'.D �G =�.0 o-� V:� s�� 3 � C C-� C � �.
� . � R ' n � �c �'7t.�� 3 n � ^u E .� � �M �. .Z, t'-. � �T' � .
n ✓ � ��i'� L�^ C L't ~ R c .. � f n '�C .
. . . . " ' , � . . p q ti� c �t � F_ t � SY v i�,��' �.#, y,i � �c n � . � .
• � � .. c_R � �� ~.c�o.•c `^ �t n^��-�'`�� � �"a ti' Cr .
. . � . � 7 - �7 � R � 3 h n . r��Te a'�rX,��t� -�, ��:e C�
. . . �; G• _ = 6 �i,� �c.� ' _= � a g . ... r,.
r � a.s„c » c c r � c x: a : •c� �gc
. � ry P�.Q 1�` «w�,� L�w� ,c,�; i.,v��.;;�i N E �
"," `�j A � t;, � &�� n �C ��o G,a C" �o'R � c r.;, rt 'Y
, , � �.E t' � «� n � C T�. w � G t�. 4 :1 c R'< �',C7 �
, . .. � ' . . . � . � C �� ^.'' !. w� G'Cr +c Y. x.E - � � C O ..•
. . . ,� ^ C C� G � s � � ! « L' �C � D .
' . . . , � S��S i C F-� e� C�`Y � �a � �.1 .-f
_
. ` . . . . ' � e Y �'t F �: V^ = ;"6.'� y+Q{�,.+ � �`i�' O yCra» L
/ . . . . . b R .. C 3 3 � �. . C � � � p'C C`t' t .-.C ..
' � � .C 3 E ~ �G M1 C -��'C ?t'-�A » �^p � C .'.v��'_.
. ' � ^ '° C � y,F w 7� � , �J 3 ~ c' _ 1° '0"
...,v�m � 3 c�-.c'1 x $��,° c�'- -
. + � �,��-�'_ �
' �'`�