Loading...
HomeMy WebLinkAbout1238A WORKERS'COMPENSATION DECLARATION - � I hereby affirm that I have a cmtificoie of mnsent to self � '� � � insure,or a cenificate of Workars'Compensofian Insuronce,or ?°�`��� � - ace��ifi�������r�,��or�ont .Indemnity O,�`��B,B„ . � . � ..ppPLICATION FOR PERMIT .. Policy N . ❑Certified copy is hereby fvrnished. � . _ . . .. SEWE� - SEWAGE D15POSAL �� � � �. :_ �Cerufed co is Flled wirh the counry 'Iding inapecti n COUNTY OF l05 ANGELES BUILDING AND SAFETY de�/�fiFr��6 RCR By l- ' Dare � Appticom �/ .� FOR APPUCANT TO FILL IN! � � CONNECTION OATA � - CERTlF!C M�NSATIONOINSURANCEQRKERS' �pp�fu 14427 E. Gold 011lt 1 e SUT10N ' DEPTH� � • (Thia section need not be compieted if ths work involved by the i�iirv Diamond Bar . �+.N�«E RE��� - -� 1°PE° ' permit is ior one hundrod do�loro(SI00)o�lefa:) . � � R � I mrtify thal in fhe performance of�he work for which �his ROS�SSSi. TYPEa��NNK��ON , �ry�7HfROM _ � permit ia'iseued,I sholl nor employ any person in ony manner �� NRB V.4 M.L 70 P.l. so os to become sub"ect ro the Worken:Com enaotion Laws. �� ' � ''�•D1O�� /��?� � � , P OWNFR CO.IMP.NO. JOB NO. � �IDRE55 P•0. BO X ��Z 7 ' 7RUNC PFRMIT NO. ' ROAD RRMIT ND, ' /��p���e Applimnt � � I ���E TO APPIICANi: If, aNer moking t{li5 CBfti�iCOtB Of �„Y- � Covina , 818-967-9541 AFFIDAVIi WAIVER EASEMENt VECORO.INSiR.Np. DAiE `c,.emption, you should�become subjecf to the Wo�keri IEGFI ,�- Compensotion provisions of�he Labor code,you must forlhwifh - pFSceipriora � - lor - H,�,y,Op 5T,wi�ENir�G comply wHh such provisions or rhis permir sholl be deemed � � ravoked. � � � � . � . e�oc[ TR SiATE E4CROACHMEM � LICENSED CONTRACTORS DECLARATION - � . ei r�arnrt r�o. I hereby affirm fhal I om liceased under prov'�sians of Choptx . 5¢eDF�07 � � ow oN�or� . � '9 commentin th Settion 7000 of Division 3 of fhe 6usi- �� Residential- � aAa�S ( g�+� )� ewmwcs neu ond Profeseians Code,and my licansa Is in full force and .. . .. .. °"°�' 336428 C-36 roNTRA�,� nC CONNECfIONCHARG[iEE � licensc NuR�,��c.C�S�1L/O�� ... A�pE� f REUABURSEMENT fEf O v� Contracfor D01e � � OISiRICI NO. GROUF nwv cacces5eo Br V a,v • rzi.N � � � p ❑1 om exempt under Set. of the L.A.Co. ST�Ns[nq. � �cinss � PlombingCodeand/arSec � ofthe �� DESCFIPTIONOFWORK r�e •^ FlNAt � FIOUSE$EVIER CONNECfING TO . /!7 �_ DFTE �� � VALIDA ON "' B.8 P.Code for the following reason y��qN RyEp��Pii pp � J FlNA /y� � Z F15 ANDioW oan�w�Elp DOfB rypUSE SEN/fR CONNECTING 70 B� � PRNqtE OISPOSAI Y f M Signafure cONNFCi MoiTiOnV,l ei�c.oa � ► OWNER-BUIIDER DECIARATION � Wa+K ro Nous�sewEa ONERfIOW SEEPA %7.�RRINiIEID �/'1reby affirm that I am eKampt from the Coniracror's license �- ex�r+..cessvooi,oavwEu.mnNHote -� ,. ., . � � ;for the following reason(Secton 7031.5,Buisness and Pro- atEW,reFvniR oa nfl..raDor�Hous[ . � TC5510l1S COde�: . SFWER Oft DISPOSAI SYSLEM , !')�a g� ❑I,as ownar of the proparty,or my amployeas with wages as �s m�,o� O their sole compensafion,will do the work and the structure . is not Intendad or offerad for sale(Section 704A,Business Permit. .s �. . I P-0���.ri d ond Professions Code). �� OWNER'S 0 D - . ❑I,as owner oi ihe property,am exdus�vely comraning with AUTHORIZATION TOTAL FEE (j � � e 2 7,E 0� licensed cont�octors to construct the projad(Section 7044, � �HAYE Ai LHIS OATE A CONT4ACi WITM THE HEREiN NAME�CONTPACTOR W � �-- � � BUSiI1p55 011(I PlOIBSSiOf15 COCIEJ. CONNER TNE ABOVE DESCRIBED E%ISTING OWELIING TO TNE GUYIC SEWF1t O f�n C��L - CONSTRUCTION LENDING AGENCY ��� � � - � �, � . . .. .. G G� V I hareby oHirm Ihvt lhera is a conshuc�ion lending pqency SIGNED THIS DAY OP � 19_ , for the performance of Ihe work for whith this permit (s W'�R� � '� - ' - ' ���� - ' ' � issued(Sac.3097�Civ.C.�. �'��AGENT ADDRE55 � Lender's Nome � -- �� ����� � Lendels Address � � � � ' �� � -- � �- I cartify thot I hove read�his opp�icotion and s�are thar the � . obove informatian is co�roU.I agree to comply wilh pll County , � � '� - - - . ordinonces and Sta�e laws ragolating Plumbing ond Sewers, � � ' � aqpndaqh�ereby authorize representatives of�his Cpo�un,pty ipop enror � - - � - � � �� � � � - iCl+Athqpbov �entione�p�o��l,(nspy_c!lOu/O�s. . � . . . . � .. . D,Y' O � Signafure of Permilfee Dafe . - SEE REVERSE FOR FXPtANATORY LANGUA6E ' ' ` ' ' INSPEQOR'S NOTES . OWNF.R-BUILDER DSCLARATION , APPROVALS �^^TE - iNs�cTat's s��rvnTwc � ' " 1 hereby afEirm that I am esempt from tLe Contrettor's r,�,���R . . . � . . . . . ... License Law for the fol(oning emamn(S�ctiois 7031.5, . caaccr wanowa� - .-. (. �.. . .. . . �. ,. .. B�iwers.ewd ProJasio�a Codsk Awy�dty or eouxty sunaw o+t woau . . - -. � � . . . .. �. mbitb.iaqriaes a'ptnwit to co�atr�tt.nJur,Gx�otir. . : . .. . . . .-�.._,. �� � _ stmc TNwt,sftv viils) ' ' � '�'i'' darnol6b.�ar rn0atr mey abrelrn.Prbr to Jk lttronte, ,woiov qwnrifw . _ . . - ...... .. ...� . �_. ._ . . .-. . _ . . . also reqrms tbe applimwt Jor�rcb pomiit to ffle a � ., : �..�,�� �,. �' :..� � signed stafM+ntt tlwt!x.i*lianed¢nnra�t to tbt � assroa❑ � onrweu❑ - . -.._..-_. ._-' proviuiows oJ tbe Cowbueror's�L:cnue Lam(Cbqptn 9 � unx,qEs�u�.sEw[a oa - - - - � . ... . � : .: � � (cornrneMciwg wJtb S�ttiow 70Q01 al Direriow 3 of tJx � swM�asaos�u srsrEra oumrvr�sa auc nra � Bwsinau aed Plojrssiors Cad�J or tbet be sa asympr ,.w,00n nousE s�R _ _ . .. . - _ � ,eae.e,/rora a»d ea.amio Jor ta.aH�g�d ar.s.ptio..Awy � e�aniu srnc taa+cs O . . .._ ' .. , ;, �. . � viaJalloa ojSecJion 7031�S bY�Y aPA�•tJor a prrnrif , . s�ev,nr s O eessvoots❑ . ._-�� - - � --. . ... �.-._.:�� � �.. ._ .. .. swbjects fbr appJkant eo a etedl p��aly of sot+norc tbm� . � . _._ . _ . ' . . l�oe bwed.wd dollarr(t300%: . . , � . . -i.-,..- . .. . . • • . � � L7 i,es the owner of t6e property will do t6e r���aad _ __. _.' . -.-- , die suucture ie aot iatended or oHered for ee3c.. . (Sec. 7044,Bwi�r�n mid RoJneioas Codr. Tbi Cow- . . � __- __.. . _.. . _.._.. . � �, . . . . tracbr's LkMua Loru da�s�ot app1Y m aw o�er oJ . ... - - . . DroMrtY wbo bwJldr or&nprows tb�noK�ad wbo dasz � .- . . . .� . . . .. . . sacb wori binualJ pronid�d tbat srrb linfrouemwttr � � are+at iatawdcd or ofjer�d jvr ad�.IJ,bo�u�ver.tbc . .. .- .. . . . .. _ �� ., _.: : _,; . � � b�ildieg or lraprowmeMt b roJd toitbis au 9��5� . . . ---- . ... _ . , .�_... .. . . corwpletiow. [be oununbrilder+ai11 baw elw bwdeK - - .. _. . . _.. _. . _-. .. . ,. ..,__._ . ... ' oj.Proving tbat ba did wot 8rlld or&s¢rvw fw tbe prrpoaeoJwlo.1 .., _:. . _ _ _.._; , __ _ ... _ I am eaeaupt uader Sec. , � ` . .... r, - - . , . . , . . . B&P.C.for this teason � `',_ . - _. Date __: . . - - Ownet . - INSPECTOR'S NOTES � _ .... . � � . . ' . . . . � . I , . - .. . . . . . . . � � �. .. ' . . . _ , - . . � . � _ ._.. � . � . J, ,