HomeMy WebLinkAboutNo Permit Number WORKERS'COMPENSATION DECLARATION � � � .' . . ..
sby affirm thot I have a certificate of consent to salf ���C� . �Q
e,or a cedificate of Workera'Compensntion Insurance,or � �^^�p � �-��� �/
�'""°�`°P'''`'"°°'cs°`.�°°,iae`., "�'°"B,°„ APPLICATION FOR PERMIT `� �`��
,licy Nori+,���c�gpny �ty �° � SEWER - SEWAGE DISPOSAL � � �
�Certified mpy is hereby(urnished. , .
[�c��rr�ed�oPy�s Rt�d wi�h�he counry 6utl ��e��:P��r�o� 530,(•.�� �OUNTY OF LOS ANGELES BUILDING AND SAFETV '
de 6%�eti�a
�ie �PP���o�� RC!{ B : FOR APPLICANT TO FILL IN CONNECTION DATA
� CER7IFICATE OF EXEMPTION FROM WORKERS' �iipi� �
COMPENSATION INSURANCE Aoors�ss 301 Fern Place STNTION � _ DEPTH �
(Thii eedioo need not be tompleled if ihe work involvad by the . nv,w+aE qEFEffr�CE u�c[R
permit is for one hundred dollors(5100)or less.) ���T�' Diamond Bar R
' �cer�ify thal in the performance of the work for which�n�s - � �sssr. Golden Springs rv�oFwnx��nora ��TMF�
rmit is iuoed,I shall�not am lo an v. cuce P.L. M.L TOP.L ,�
pe p y y porson in any manner . P�� ,��(,��
w os ro batome subject�o Ihe Wotkers'Compenwtion Lows. pwNFq m.ina.tio. ioe No. �s��
Da�e Applitont
�""ooffss P.�. Box 3329 T�u"Kv�RMirno. Qo.ov�aMirrao.
NOTICf TO AVPLICANT: If� p+f@f MOkin 1�115 CO�IiFi[O�E of � COVlria 818-y67-9541 ARIDAVII WAIVfR EASFMEM RECORO.INSlR.NO. DALE
9 CITY TEL NO.
Eaemption, you should become subject to the Workan' i�q� �
' Compemaiion provisio�s of the Labor code,you mus�forthwi�h �R�pnpa iorw.� Hwr,pe St.wioeNuac
� comply wifh s�ch provisions or this permit sholl 6c deemed
�revoked. � � ' ' ' � e�ocK iRACT SIAiEENCROACMMENT
�.� VERMIT NO.
' LI[ENSED CONiRACiORS DKLARATION �,��ioT r�n,pr.�wT� •
� I hereby affirm tho�I am licensed under provialons of Chapter �a
C(commendng with Secfion 7000)o(Division 3 of tha Busi- �iip� esiden anar,cs
nns ond Rofessiona Coda,and my license is in full force and .
CffCN. - ' Cpp�iq,�,Rpq CONNECTION CHA4GE ffE
L�censeNumbe. 33b42ts lic.Class C—,S6 nn�u 12 Ma LS REIMBURSENENTFEE d
RI;R P1,UM1sIN�, 6/16/t56 �,,,, Riverside. ,��.�.,0]14-371-5000 DISTYIQNO. GIIOUP �P PROCESSE�BY �
contrado� e e� ac
❑I am exempt under Sec. of the L.A.Co. � ii�µ�r.�p ��,� C— !d
NO. DE$�RIPfION OF WORi( fEE ~
� Plumbing Code and/or Sec. of ihe FiHµ V
HWSE SEWER CONNFCTN+G TO on,e �_j_$ VALIDATION a
aueuc sewrx
� B.B P.Code for�he following reason . s�vri�uNc,s�a�rit oa ��3 C7' �
VITS AND/OR DRNNFIELD fINAI •� � '
�o1R HpuSE SEwEc CWmECTir�G TO . BY j�e o a
PnNniE Di5ro5nt Sr �
. $ignO/uIe �� CpNN[Cl qpp�TipPu,l NpG.pq
- OWNER-BUILDER DECLARATiON W°�T°�s�s�'�"ER , � a"[�.�� I
OVFRfIOW SFEPq NT,pRA1NfElD
I hereby offirm thot I am exempt from the CoNrottor's litanse - tx�H.,c�s,wop,d�rv�u,r�aw/ae �,� `�;N�
Law for the following reasan(Secton 7031.5,Buisness ond Pro- uha,ueo��a ce�eee+DOia�+OuSe - � � ._ o
flSSiOnSCOde�: HWEROROi5o0YA5Y57EM p`� -� �
�U�y
❑I,os owner of the proper�y,or my employees with wages os r�= °�i v
their sole tompenwtion,will do the work and the z�r�tl�re � � � � � �
is no�intended or oNered for w�e(Section 7044,8usinass
and Professions Code). � aWNER'S Permit f � l , .
❑I,as owner of the properry,am exclusively contracting wi�h AUTHORIZATION TOTAL FEE � �
licensed tontradors b conslr�tt the projecl(Section�044; ' �HAy[Ai THI$DFiE A CONTR/R WIiH iME NFREIN NAMED C0�11YACfpQ TO - -
BVSInE53 011d Pf0{OSSIOnS COdE�. CONNECT THE ABOYE DfXRIBED EXISTIFIG DWEtIING i0 TNE P�&IC SEVIER.
CONSTRUCTION LENDING AGENCY � ► �- � -- �
I hereby affirm Ihot lhere is a mnstruclion lending agency SiGNEDTNIS DAVOF 19_
tor the performance oi �he work for which this permlt is ' ��°Oa � - - � � � �
OWNEQ$AGENT
issued(Sec.3097,Civ.C.�. � -
ADORE55
lender's Name ' � '
Lender's Address � � �- - '
I certify that I have read this application and slate Iha1 the •
above informo�ion is correct.I ag�ae to comply with all Covmy . - - - � � � .
ordina�ces and Sta�e laws regutating Plumbing and Sewerz, . �
and hereby autho�ize representatives of this Counly 10 enter - � � - �
on the abov menlioned property for inspection purposea.
�i:R S :� ,
y Lih1D_I�7�t. 6/16/86
Signofure of Permilfee Do!e . SEE REVERSE FOR EXPLANATONY LANGUAGE
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