The URL can be used to link to this page

Home My WebLink About1239A (6) _- - _ . _ ____ _. __._ _ .,., _.._ _... _ _ _.. .. _ � WORKERS'COMPENSATION PECIARATION � ' I hereby affirm that I have a canificota of consenr lo self � inwre,or a cariifimte of Workers'Compenm�ion In�umnce,or �ena2o _ �� - � awriifi�o$��o�,�on��nt Ina�ity . �:��`v�e,B" _. : . pppLICATION FOR PERMIT Policy N . . . ❑Certified topy is hereby fumished. � � ' � � . . . SEWER - SEWAGE DISPOSAL � - .. - ..� �Certified co�pY is filed wi�h�he county b 'ding inspec�i n S3U�/ COUNTY OF LOS ANGELES BWLpING AND SAFETY d��fifPYtsb RCR By: L��,i r ,� Date Applicont - �� . FOR APPLICANT TO FILL IN CONNECTION DATA � � � ' - CERTIFICATE OF EXEMPTION fROM WORKERS' euno,n� � � - COMFENSATION INSURANCE �� - � � �ooaEss ST�troN � ��--�- oevrH �� . �This sxtion need not be mmpieted ii�he work involved by 1he - �p�qiiiv Diamond Bar nvu+tKK¢eEr[aEy¢� � � -� uvvEx permi+is for one huodred dollan(3100)or leas.) � � q I cenify that tn�ihe performonce of the work for WF11CI1�FIiE Cpp5g55i TYPEOfCONNECTION .��TNFROM . �permil ie iasuad,I nhall not employ ony penon In ony monner . . Y� Cuae V.L M.l.TO P.l. so as to become aub'x��o Ihe Workeri Com emation LOW3. . ' � P'�'�' � I P OWNER CO.IMP.NO. Jpe NO. 1� �'�'�� ' TRVNK PERMIT NO. � NOAD PERMIT NO. ' '� �re Appli<ant ... AD�+E� ' � ��ICE TO APPLICANi: If, ofler makin ffl�t CerNficors OF AfFIDAVIT WAIVER EAS[MfNi RKO40.INSiR.PoO. DATE g c,r Covina , . SltS-967-y541 rmpfion, you ahould become aubject to 1he Workera' Compensatton provisior»of�ha Labor code,you must forthwi�h � � o�scRi�v iori � tor - � Hwr.ox 5T.wioewr+c comply wi�h such provisions or this permit ahall be deemed _ revokB(I, � � . ' � ' DIOCK TR STATE ENCFOACHMENT -. IICENSED CONTRACTORS DECIARATION 9� � RRMVi ryp. � I hero6y offirm thot I am licemed under provielons of Chopter . �'ZEOFiOT � oNior � 9(commencinfl wirh Sectio�7000)04 Division 3 of the Buai• yuEioin�s CHARGES - nma and Professions Code,and my license la in fuil force and . . � effed. � � - [olJrdEc7iON cMnkGE PEE ' . 336428 C-:i6 CONTRACiOR > d License Nu��en��c.CI��_ ,��ss � 1�ID ing, TIC � REIMBURSEMEM FEE V Can�rUC�of � � DOfe ' CITY El. DIST�tiCE NO. GWWP NJ.P VROCESSED BY � 6K GG Z ❑1 om exem �vnder Sec, � of the LA.Co. n�rE uc. . /� � Q . P UCENSE NO. - ' C1A55 V F MO. DE3CRIPfION Of WORK iEE ' ' V Plumbing Code and/or Sec. of Ihe /� �_ ryNA� �h �/g.� VA�IDAf10N d .. IqUSE SEWER C0IJNECTING TO DATE y B.8 P.Code for the following reoaon � �&��R Z . PTIC IANK.$EEPAGE PI7 OR F�u PI�S ANO/OR DRAINFrtID � . .. �1e ... MOUSF SEWEQ CONNECIING TO 8V NtN TE Y T Signo�ure . . . conmEtr,wo�Tior,µe�o�.pa , � - OWNER-BUILDER DKLARATION WO�TO�� G4E l0 EP PIT,ORnINFIflO . �^veby affirm that I am axempt hom�he Connactor's Licease E%TN.,CESSYOOI,ORYWEIL,MANHOIF � � . . . , �for the following reasoo($G[�OO 7O3I.5,BVISOB55 OOd Pf0- ALlEp.REV�IR OY ALANDON NIXIY . . f; �ressions Code): s�weR oa oiscosu svsreM �1 2 3 9 A ❑I,as owner of the properry,or my employeea wiiM wages os ��..-• • • � Q - lheir wle compenwlion,will do ihe work and the structuro ' ��" ' � ' - �--� is not�nlended or offered fo�sale($ection 7044,Businns � .�A A L 7 5� ond Profeasions Code). OWNER'S Pe�mit s p�' ❑1,as owner of�he propeny,am exclusively controcting with AUTHORIZATI�N T�TAL FEE ' r�1 � •P*G 7�Jr�L�i licensed con�wctors�o construct the pro�ecr(Section�044, �HAVE AI TMIS�ATE A CONiRACT WITH TNE HEREIN N�MED CQ`1TR�CTOR ro � - � �� - - '�' n BUSIn055 Onll P�ofeuioni COde�. CONNECT TME AflOVE OESfkIBfD Ex15TING DVIELLING TO TNE WEtI[SEWFR. O II.2 5`V 6 '�CONSTRUCTION LENDING AGENCY - ' �- � � � - � - , ' � . - - I haraby affirm Ihof fhere is a conshudion lending ogency SIGNEDTHIS �AYOf 19_ � (or �he performonce of the work for which fhis permil Is�� '�'�R� � '� - - �- - � �� OWNERS AGENi issued(Set.3097,Civ.C.J. � . lender's Nome � � �� - ' � � lender's Address � � : � � � �� -'- - - � -� - I certify thot I have read this application ond smte�hot tha � � � above information is correcL I agree 10 comply wifh pll Counfy � �� - � - � � � �, . � ' � - � ��- � � ordinnntes ond Slale lows reguloting Plombing and Sewers, � . . and hereby aulhorize ropresen�atives of Ihis County to enter -� �- . - - � �� Ib e-menlioned prop 1y tor inap t' z. � �2t �l'r�`Y�� — ��_�,.��;, Signalure o4Parmlffee Dafe SEEREVERSEFOREXYLANAtORYLANGUAGE . _ , � ` i - INSPECTOR'S NOTES OWNER-HUICDBR DECLARATION APPROVALS o^h iNsv�c�o"'s s�^'^T�'� t hereby affirm that I am e:empt fcom t6e Contrector's ' �,��R � . . . . License Law for the follow�ing re�son fSe�eiow 7031.5, �'.. � ..,. . � ��. .:.-� .;. ,�.�. .� - . � �. :-.`� . B..sissrs md PtoJasiows�Code}. Asy city-or couxty an�n�a��woxi�c .. r .`. .:- . �- . . . . �� . � - . :_-. •:. . -. � .�ubicb ragriros'n.perrolt w cowsMme.aleer,iiaprove. ' SF1fiC TANf.SEEA.%7(5) ': � . ... . �.dlblOkiE,or r�pair ory shrctrro.hrior Pv Ja fnwnce, �.- AND/OR URAINFIEID . .. .. ..-. - ' _ ._._.. _... .... .... . . .... ....... .. ... . . ., 9120 � 1b1 f OI�iYC17 . 1VQYYlt 0�001/ f QiIH1{l ZO ffj2 6 .. . - " . . rigned stal�wnat tbat b�4 licrst�d prrswxt to tEe � , ... .. . .. ,- , w �ssvoo�p_ wevweu p.._ _ . .. .. . _ . ... .. . . ... . . . . . ..prou:sia+s oJ tb.Cornacror's LtreRre Law(Cbqpt�r 9 � ara,a[r�m.sEv.�a oa -- - - . , _ _. . _ . . � _ . . . - (�o,nme�tiwg wJtb S�claos 70001 0l D'nririow 3 oJ tbc sew�cc asana�srsr� � Bw,riwars aMd Profisdorc CodrJ or,tba!be!r wrempe � n�wu�s�ir�R . . .-...-. _ - . � -- --....- ._ . . eLereJrvroi awd tb+banis or tbr . . 1 dlrgsd weempba..Asy '. ' e�c�ciu sErricTu�xcs p . . .. ..... .... ..� ;�..viofotiow oJS.ctioe 7031.5 bYWy'9p6�'��fora pem�it 7H►.RT O eessvoas❑ . _ . . � . . .� . .��:.� - au6jects ibc applkawt to o cioit pewatty ojwot rworr sbm. .,.�. . . .� , 1 ' - �tUC f/If1MlIVd dOUAi'f�sf��.: __ . .. _. .. . _. . .- .:_ _.. . _ -. _ .. '.. -: . . . .- .. . . ❑I.ast6eawnero[the �v91(dothewr"�sal , ' �j . , ._ . .,...�� , �.:.� ,.�. � , � . �.. .'��tlie stracture is cat ia or�e+ed for eale. : � . . �_ _ : . � _..... . ..._ . ____ . . .._ . . ., . , .,. . (Sec. 7044,Hreis�sr ad Rnfirsww�Cod�:Tbi Cow- ' � _ _ _.__. ._.. . . . _.. ___. .. �.. �_' ' � . . . tracto::I.ln.e.l.am do.:+we�pply m w ow��r oJ I. : . .. . . . �. ... . . .. ' AroA�'tY wbo brildr w in.proiva tbtr�o�,wd wSo doaa �, _ _ �>� .. . . .....�• srcb wwsk b6wt��p►n+idrd.tbat.ercb irrpro�nnowa ..... .. ._ � � ore wot lwte�d�d or qQ'end Jw refr.lf bnurewr.tba _ . . . . ...... _ . . . �-- � - . bu:ldirbg or i�sp�ovarrst Jr aold�olibiw aw 3'�a'9f _ -- — _ _ : rnn.pl�t:w, sba oraiorbrJldn will baae sbo bYrdeM � . . . _ . .-- , .--- - . . '_; �.�' _� . .__. _ ----- . _. � �l P�B tbas be did�ot br1W or iaprow jor tba �i . . _ .. . ,_Pr.pos�a1+de.1 . . . ._ _.. . . .. ,. _ - I am�empt under Sec.: .. i � , • - , - .. ... . _... _ . , ' ' . . S&P.C.for this reeson , _ _ _ _ _ , � __ � _. \` '` _ _ -- Date -. - Owner _ � tNSPECTOR'S NOTES . . .. ' . .� . � �� -.. . . . ' . � —` --- -� -- ----�--. . ,. � . . , . .. .,. . . ` . , f . .