HomeMy WebLinkAbout1232AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, or
a certified Policy b erh71' ,�n mon)
t Indemnity
tt
❑� Certified copy is hereby furnished.
KI Certified copy is filed with the county b ilding inspection
de"tWl.86 RCR By: f 1} .
Date Applicant .P i
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the work involved by the
permit is for one hundred dollars ($100) or leas.)
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date Applicont '
7TICE TO APPLICANT: If, after makingthis Certificate of
fnption, you should become subject .to the Workers'
Compensation provisions of the Labor code, you must forthwith
-
comply with such provisions or this permit shall be deemed
revoked.
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter
9 (commencing withSection7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and
effect' ' 336428 C-36
License Nurft--pi7tR,iB-ititc. Cbsl l6 i 86
Contractor Date
❑_ I am exempt under Sec. of the L.A. Co.
Plumbing Code and/or Sec. of the
B. B P. Code for the following reason
- OWNER -BUILDER DECLARATION
,"e,eby affirm that I am exempt from the Contractor's license
f for the following reason (Secton 7031.5, Buisness and Pro-
..,sions Code):
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business
and Professions Code).
❑ I, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Section 7044,
Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued (Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County -
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
VpgiP, IT%q oyBrmentioned property for inspOctjop,pu/Qpy_es.
Al.1C D�_r .l 1��.�1 /t •, ,U/1U OU .
Signature ll of �Permivee W1Tl}E— Date -
76A6A20 _
CE BOB (REV. B,BI) - APPLICATION FOR PERMIT
of SEWER - SEWAGE DISPOSAL
530 /-All - COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
CONNECTION DATA
ADDRESS 24 3 E..Gold oint Place
ADDRESS
STATION
°E°'"
LOCALITY Diamond Bar
MANHOLE REFERENCE
UPPER
LOWER
NEAREST
TYPE OF CONNECTION
LENGTH FROM
CROSS ST.
Y. CURB P.L.
M.L. TO P.L.
P.C. NO. .�O
OWNER -
CO. IMP. NO.
JOB NO. 3. G
AODI DESS P.O. OX. 3329
TRUNK PERMIT NO.
ROAD PERMIT NO. -
Covina_.
AFFIDAVIT WAIVER EASEMENT
RECORD. INSTR. NO, DATE
CITY -,,,,,818-967-9541
LEGAL
DESCRIPTION LO /
HWY. OR ST. WIDENING
BLOCK - T CT
STATE ENCROACHMENT
PERMIT NO.
-
SIZE OF LOT ON lOi
-
USE a
BUILDINGS Res • d nt • al
CHARGES
CONTRACTOR
CONNECTION CHARGE FEE -
ADDRESS 7- Inc
REIMBURSEMENT FEE
H765 Ma LLUI:td ftVU.
DISTRICT NO. GROUP
MAP PROCESSED BY
CITY El.
imp r -Aide
STATE UC.
/ ()
LICENSE NO. DLA$$ -
l
No. DESCRIPTION OF WORK- FEE
FINAL
PUBIC SSEEW ER CONNECTING TO Y .�
DATE y/lam/
VALI ATION
SEPTIC TANK, SEEPAGE PIT OR
FINAL
AND/OR DRAINFIELD
HOUSE SEWER CONNECTING TO
BY
PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL SE BLDG. OR
WORK TO HOUSE SEWER
H,
OVER LOW SEEPAGE PIT, DRAINFIELD
EXTN., CESSPOOL, DRYWELt. MANHOLE
-
ALTER. REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
-
-.
.. ,�^. 12 a C A
d
p...10
OWNER'S Permit $Q
d 'B " 2750AUTHORIZATION
TOTAL FEE
* • R 7, 5 0
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. 2 B 5-8 6
SIGNED THIS DAY OF 19_ 11 O L
OWNER OR
OWNERS AGENT
ADDRESS
SEE REVERSE FOR EXPLANATORY LANGUAGE
APPROVALS DATE INSPECTORS SIGNATURE
NEW MOUSE SEWER
CONNECT ADD11IONAt. - - ..-. ._:
BUKDING OR WORK
SEPnC TANK, SEEP 11T(S)ANDiaR DRaNT�Etn
CESSPOOL O DRYWELL Q - .. --- - -
ALTER, WAIR, SEWER OR
SEWAGE DISPOSAL SYSTEM
DISCONNECT RUG AND
ABANDON MOUSE SEWER - - _-
OAULPItL SEPUC TANKS ❑
SEEP, rn O CESSPOOLS ❑ -
INSPECTOR'S NOTES OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Sectio* 7031.5,
. - - Bwimss aril, Professions Codek Any city or county
which requires a potwit to cow*wct, alter, improve,
I daisoksb, or repair any structure, prior so its issuance,
_ - _ .. .. _._ ...... . .. .... also requires the applicant Jor sucb permit to file a
signed statement that be is licrated pursuant to the
provisions of the Contractor's Licence Low (Cbapbr 9
. .. (commencing with Sectio* 7000) of Divittion 3 of the
Business and Professions Codal or that be is exempt
therefrom and the basis for the alleged exemption. A*y
violation oJSsction 7031.5 by any apftkmxt fora permit
subjects the appiicant to a civil ptaalty of": more tban
Jive bundred doAm (5001•.
❑ 1, as the owner of the property will do the wo'� and
_.. the structure is not intended or offered for sale:
(Sec. 7044, Business and Prefesrious Code: 7W* Cox-
'+ tractor's Lfeense Lau does not apply to an owner of
_ - property who brildr or improves tbereou, Bad sato does
.. --- such soork himself provided that nucb improvements
are tot intended or offered for sale. If,, however, the
k - - .. ....... - .... r .. :. buildlgg or imprauemert is sold w&bin one year of
- - completion, the osonor4ailder will bow she brnien
of proving that he did not build or improve Jor the
purpose of salol .
�:.... I am exempt under Sec.
P
B & P.C. for this reason
.Date
Owner
INSPECTOR'S NOTES