HomeMy WebLinkAbout1499A (8)scr,�^t`�3 e'-'"�:r,�'s,Twi"Ky?'5�'"�`. *+.:J3.-;.,. r'�,'�:'':�i .•.:rc'Y. s iz'.--�u5",,c:r.w„ �€ ,.r,�s�§�, :�y`rn`°.F�„"n.:s.,,�.,-s.�--A-h��.--�,�-,^t^;"^-' ,,, - - -
WORKERS' COMPENSATION DECLARATION1, 4-
w
1he eby'affirm chat. I have a certlf cote of consent "to self " ^" ' '
., insure or a certificateof Workers' Com ensdt on Insurance or " MA642D -
P FUnd
' 'art fied� cop tFe of Sec �8db " C:). _ ., _ .,,,,.
16
Po( cy No ,� Company ®s - C�j(/ /s yam'
r,.�Cert I KerFby, fern i shed - SEWER.Se•iAG DVSPVSKL
3* z � Cer2t�find, copy is filed with the, county building inspection. COUNTY"ZiF.1,6$-ANGELS 'BUd131NG AN6 SAFETY "
the
this"
ner
n,you s}iou�fd become su6lecY, to the Workers'
bt'on piovis, o'n's of_tthe'Labor code, you must forthwith
vith such -provisions or this :permit shall be deemed
afifirrn that I'am Lcensec� under
;s`6f Chapter "
eh<mg with Se<tlon 700a� o Drvis16r, 3 of the Susi
Profess ons Code andmy license 15. in fUlf force and
umber 11.% O$'� Lic Class- ('34il^
I'eEffiaTl Date" 81 20J>�
FOR APPLICANT TO'FiLL TN"
CONNECTION DATA
BUILDING - (
ADDRESS'
STATION ', - ,.
- DEPTH -
.LOCALITY `-'-
MANHOLE REFERENCE -
UPPER
TOWER
NEAREST .,.
TYPE OF [ONNECTION
..... ,..,..-".... ......"-....
LENGTH FROM
CROSS ST.
Y. ,.CURB-"'
P.L. MAL TO P.
OWNER` ANDEN GRP.::.-.. .. :
CO IMP. NO...
,Sale
IS.
MAIL
ADDRESS- -Box - -
.--
TRJNK PERMIT NO. -
ROAD PERMIT NO.
qq -
- AFFIDAVIT WAIVER .EASEMENT RECORD. INSTR. NO, DATE
CIN Covina . TEL. NO
na.
CONNECT THE ABOVEDESCR
!§7kU�ribn7
LEGAL
naf 7}le6 sa construction endng agency
SIGNED THIS
DESCRIPTION " LOTNC
HWY. OR ST.: WIDENING
..._. _
BLOCK -'.: .TRACT 754
STATE ENCROACHMENT
{y
NO OF&DG5 -
PERMIT NO.-
-
SICEOFLOT " NOW'OTYL"OY""
�y.
BUILDINGS Sigg. Res
•-
CHARGES
�Try�y�,T [P}n
CONTRACTOR yytiyyy^ri•11yyV{lV
CONNECTION;. CHAk'GE FEE.:
ADDRESS _ _ ', f �-�
REIMBURSEMENT EE
�^I8225
r7aaT r
fill, `�
DISTRICT NO.
MAPS
PROCESSED BY '
CITY-' Gaa ,L (." ma. TEl` NO j 1 .960—
10ROL11
SK '- PG
'
LJSTATE ENO.4 (`hV8f • ,. .9j .•:_ ,-fit- C�.�.:;,,
ICEN V
NO.- DESCRIPTION OF WORK "FEE=`
aGro.:: - ... ]_`,� �0
coNNEct0 O7vA
iVNE.R BU fLtO`ER bE`LlK2kC`flbV ' "�
WORK TO H00SE $Ev
it I om exempt from theCo_niractor s L'Gense "
OVERFLOW SEEPAGE I
ExTN ,CESSPOOL, DR
Ing reason (Svcion 7b r: Jt,TBU15n85S -P/id Pro
'ALTER; REPAIR'OR'A0
:SEWER OR DISPOSAL
the,properly, or my employees with wages as"
pensanon, WIIf do the work and the structure
-
d or offered for(Se6lcm 7044; ELiSine'ss -
ON -HOUSE
EM
,Sale
IS.
OWNER'S'
the property, am exclusively contracting-wnh
ALITHOMATIOIV
""Ors 10 COnSiTU, Ct„the . project (Sect) ori.;. 7044
1 HAVEATTHIS DATE -A C(
'rofiesslons
CONNECT THE ABOVEDESCR
!§7kU�ribn7
naf 7}le6 sa construction endng agency
SIGNED THIS
nce of the work for which this permit is
OWNER.OR
Civ C I '.
OWNERS.AGvT
aGro.:: - ... ]_`,� �0
YATE DATE C7. /`i
/
�
VALIDATION IL
N
OR ”
FINAL - ...
ELb011.
LRAM
OLE
-
ON -HOUSE
EM
:- 1 [i- 9i:P A -
tq
, a 27:50
Permit g �j ,
TOTAL FEE ' 5d
2 7„5 0 25
TACT'WTTH THE HEIj�IN NAMED CONTRACTOR TO)'±
'EkTSTING DWEL[1YJG'TO'TpFfE'pUBffC`Sr"WER`""
-86 - -
{y
19i�
+r .
t r r x „iiJSPEt40& S PIOYES
2 OWNER-1BtTILDER l� C� AT$�37[bPT
: e y.
a lN
, ,
sl
APPROVALS
DATE' ` MACTOR3 SIGNATURE
...
hereby afikm that Z am e"S rapt fronaLt a Contractot s
.
—•
License Law ior'thi following 7031.5,
NEW HOUSE SEWER
,reason(Section
'Business -and Professioas'Code): Any city'-ae eoanty
CONNECT ADDITIONAL
_. ._ ..
- which requires a permit to comslaatrt alter' improve,
BUILDING OR WORK
demO%h ®rf¢epar any strtictura pYW19;80 its issuance,
_.
SEPTIC TANK, SEEP, PIT($)y�ya�-_
-
... •.-- .
-: also requires th6 appletantT ssuh p6rmlt t0 J' a...
AND/OR 0RAINf1ElD
stgaed Statement: that he ,is.: licensed pursalaut to. the
CESSPOOL ❑. DRYWEL! ❑
-....
prouuions of the Conte°actor`s LiceaFse law (Chapter 9
rixµ
ALTER;REPAIR, SEWER OR
_.
1 -
(Commencing whir Section '7000) of 1Bnsslon 3 of th¢
^. •
'.
SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
.
..`
�.
Business and jcrvfessioas Code) or thai'. he is exempt
therefrom the. %lai'r's fOP the alleged a remptian. Any
ABANDON HOUSE SEWER
.. _ ..:
.;. and
-.,.. , ' ✓ �.,q...>».., .. .:wrw..',...-,..... .
on I
BACKFILL SEPTIC TANKS [�
$EP PITS ❑ CESSPOOLS O
, _, pp ant to a 24911 earl nog more than.
.,,- '. iiT•l ,, t
red (8500)..,
500)
..
'T _ _„ .-
pL'Yt}''WI �6the WOY��{S
��&n owner of and
T /'' # 3 Y
' the 5ffivctum is not iIIteaidefi or offered for ale.
,f
(Sec 7044 Baseness and &'s+ofeasiaons Coda "�°k'
q - ..
'
. .{
gLaw does „not, apply to an o% Of
lair%(a3 does
+_.
• t x
j °S
s '
tr -.
pro�erty whO or meproves thereon, and who
inch, nt himself ed r� seed fo le such rmpronemenRs
ided. tba
are no e. of - - t however, the
` •
C a
8u(klaar or Im rovement as sold wit a one year of
completion,, the ownenbz ikw uili have the burden
...
e --or improve"for
� of p se ofsalc>>� Ir did not ild the
a
B&�e this1'�SOII�_.Te.
-
_
Date lAaiE
vA
4
i.'i "aR 7jfi'yR a^t ..
Vf' er
6WYl�1
- BNSPEcrtwsN®YW"',�
;-.-,
-
4
+r .