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HomeMy WebLinkAbout1241A IWORKERS'COMPENSAiION pECLARA710N . . � n 1 hare6y aff�rm �hot 1 hove o cerrificme oP consenl ro stlf ��p � . �IS ' insure,or a cenificaro of Wwke�s'Compenaotion Insurance,or � � - � � � �� � a cel�ified copy thereof(Sac.9800,�ab�., � �F�„��.e,e„ . . APPLICATION FOR PERMIT � PolicY N�-����^Y ty �s . . . . _ . ❑ce��+���aPr ia hereby fumished: SEWER - SEWAGE DISPOSAL _ �Ca��iTied copy ia filad wiih rhs munty b Iding inapeuion � COUNTY OF lOS ANGELES BUILDING AND SAFETY �1e`�i JY.�i J'86APP�.�a��RCR By� y� ��� ppR APPLICANT TO FILL IN CONNECTION DATA �CERTIFICATE OF EXEMPf10N FROM WORKERS' euuoinK . . _ . . ' COMPENSATION INSURANCE �� � � � ��55. 2 Old O1 t PL ST�iroN OEPTH (This section need not be compbred if rhe work involved by fhe i�i��� Diamond Bar MM'M�OIE AEfERENCE ' � UPPER � - permif is for one hundred dollms(3100)or less.) � � � 1 certify rfia��n the perlwmance of�he work for.which fhts C�qps�sgi, .TYPE Of�ONNE�i�qJ,. IFN6TN FROM� . ' mit is iuved,I sho�l not em lo an Y� NR9' i.L M.L TOO.L per p y y person in ony monner P�� � so os ro becoma subjecf to ihe Workers'Compenw�ion laws. owr�a m.��nr.ra. � - ioe r+o. fl� �/ � �n�e nppucant ' Ao��u P.O. BOX �J3L TRUNKPERMITNO. ' ROADPERMITNO. f ICE TO APPLICANT: If, after makiny this Certifico�e of - �it� COVILIA 818-y67-9541 �FIDAVIT wnwte e�sEn+enr RECORO.INSTR.NO. OAtE l+rtmp�ion, you sbould become subjxt �o tha Workers' tecnt � Compenaation provisions of the Labor code,yoo muat forrhwith -� oEscc�nriorr � iorra � � Hwr.qt sr,w�oeNinG comply wirh such provisions or rhis permit sholl be deemed revoked. - � - � eiocK iRACI SiATEENCROACHMFN� & PFRMIi NO. . LICENSED CONTRACTORS DECIARATION s¢E oF ior oro�or� I hereby aHirm�that 1 am licensed under proviaionz of Chopbr � � �9(commenc�ny with Seufon 7000)of Div�sion 3 of�hs Busi- e�lows ResidenCial a��s � neas ond Profeuions Code,ond my license is in full force and� . � � . � �HGC�. �+ - � �pNTRAC1qt CONNECiION CHANGE FfE �. L'IClnslNumber 336428. i;�.��gu 1��.�6 Ap��� . . 1 ) C REIMlURSEMENiFEE , Q RC�� b�- oisraia rio. cnouv n+rw vaocEsseo er v Connoc�or � ro � � aTr - �.No. F aa vc Q yo ❑I am exampt under Sea �af tha L.A.Co, uciNsc ra. ci�5 _ r Plumbin Code ond/or Set. ' of�he �' ��RIVfION OF WORK FEE " F�n,A� V 9 �ause sewea coNNeawc ro onT¢ �i,/�/�� VALIDA ION d vu�ie sewet N 8:8 P.Code for the following reoson I�iANk,$[fGAGE VI7 OR F�Nqi 2 vI15 AND/OR DRAINFIEtp ' ��e 11OUSE SEWER CONNELTING 70 . eY . . PItlV0.tE DI l SY T M $IgnnlUro �� CdVNlCT�OOiiIONAI SIDG.pR� ► � � - �OWNER-BUILDER DECLARA710N � woae�o House sewFa . O�FRFIOW$EEPAGE PIT.pNA1NFlFLD . ' .reby aNirm thot I am exempt from the Conlracfor's License � - [xTN.,cessroa,okrwcu.hu�o�[ - " , . . .. ... .� � �for rhe following reason(Secton 7031.5�BVISOE55 Ofld Pf0- � AL1ER,REiA1R OR ABANOON MOUSE �OnS COdB�: � SE`HER OR��SPoSAL SYSTEM , , , - - . , ' ❑I,os owner of the proparty,or my employees with wages as � . their sole compenwtion,will do the work and the structure � � � - ' �� . is not in�ended or offered for sale(SeUion 7044,Business . ond Profesa�ons Code). OWNER'S Permif S /Q �'� ❑I,as owner of the property,om exclusively controcting with AUTHORIZATIOI� 70TAL FEE � (� �� 2%,� A �iCl�SCd contractors fo consiruct the project(Seclion 7044� I HAVE AT TNiS p41E A CONtRACT W17H TM XERfiN NM1E0 CW�ITRACTpR 10 � , BUSinB55 Ond PfOflSsIOnS CO(IBJ. ' CONNECT THE ABOVE DESCR�BED ExiSTiNG DWElL1NG TO 1HE PUBtIC SEWER. j�,m o 1 0 � O � CONSiRUCiION LENDING AGENCY - '� � ' �� -- � I hereby affirm that rhere is a mnstrutlion lending agency 9G7.�DTH15 6AYpF � 19� ► � t.�a�'�Jr O for the performonce of the work for which rhis permit is °W�R� � - � . - isaued(Sec.3097�CiV.C.�. OWNERSAGENT F �ooacss •�7...�?� Lender"s Nome n�2 5�8 6 Lendx i Address - - . � . � . . - ` � I cei�ify iMof I hove rood this applicalion and s�ate tha�the � , � � obove informotion is co`rett.1 agree to comply with all County � _ ' � � � � ' - - ' � -- � - ordinances and Swte laws regulating Plumbing ond Sewers, � � ' ond hereby authorize represeMolives of Ihis County fa enler � - � - � � � � � . �� up`RheBabov meniioned pro�jerfy(or inspection purposes. � . . i( y`�A�u.Q��.u-N�"r 6/16/86 Signo�uro of Permiltee Dale SEE RFVERSEFOR E%PLANATORY LANGUAGE � _ ,. .,. . _ G �; ,,, :f g :i� ` I . : F � _ _ P f _ . _ j _ � __ _ _ _ • saior+s.ao�asN� ; . � , a ... • .np _. _ . . 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