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HomeMy WebLinkAbout1232A (6) � WORKERS'COMPENSATION DECLARAT�ON � � - ' � q I hareby affirm fMt I hove a certificale af consent to self � � � � � insure,w e certifimte of Wwkers'Compenw�ion Inwrante,or �ane.zo , . Poi"Y'`'��'�'"����r`°�bnont �ndemn�ty 0s�°°`R`°.°�e" - APPLICATION FOR PERMIT ❑Certified mpy ia hereby furniahad. - . . . . .SEWER - SEWAGE DISPOSAL- -� � � �]Certi(ied cop is ffled with the counry 6 ildinq tnsPacnon 530� COUNTY OF LOS ANGELES BUILDING AND SAFETY d'�fj9E`3'�r'/�6 RCR By: i 1} _.: ; oa�, MPu�am �ld�i1.2- FOR APPLICANT TO FILI IN CONNECTION DATA ' CERTIFICATE OF EXEMPTION FROM WORKERS' � p�iip� - � COMPENSATIONINSVRANCE � � � . A�E55 2�/ :i E. .Gold oint Place ST'°T�or� DEmN ' _ (This section nevd no�be completed if the work invoived by ihe Diamond Bar - �+�aE���N� � � � - . � °P°ER � permi�ia for one hundred do�lais(SI00)or leas.) � . ����TY � R � ��I certi(y that in the performaoce of the work for which this ceosssr. tv�orcoNNettiorJ �N�THFRpm . permit ia isaued,I shail not emplay any penon in any manner Y� 'CVRB V.L �M1�L TO P.L. so os fo becorne wb'ect to�he Wakers'Com nsarion laws. . � � � °'�'NO' ��d 3 G� � � OWNER CA.IMV.NO. JOB NO. .. Date Applicont ' A�oo�aEss P.O• OX. �,J L _ iRUNK PFRMIT NO. � 'ROAO VERMIT Np. - . ' ��TICE TO APPIfCANT: If,� afle/ making fhis Certificate of ��Ty - COVlI18 818-967-9541 ^f�ionvrt WAtVEN FASEMENT RKORD.INSTR.NO. OAIE .mp��on, you should become�subjeu .ro rhe Workers' ��qi �� � Compensation provisions of the labor code,you must forihwilh- oexaivriow �o . I HIW.ORST.WIOfNING � comply with wch p.ovisions or fhis permit shall be deemed �evoked. � ' � eiocK - T CT STATE ENCFOACHMENT . . � UCENSEU CONTRACTORS DECLARATION� � . r�RM�r"°. . - � sizeoFwr - oraioT� - � 1 heroby offirm lhat I om licensed under provitions of Chaple� �� � �9(commencing�with-SeUion 7000j oF Divisian 3 of ihe a�s�- �,��0���5 �Res'd nt'al CHARGES �� nest and Profeasions Code,ond my license is in fuil force and . . . effect. . 336428 C-36 coNTaaROR coN�cnoNCNnac,�r�e License N c.C s - �- C R[iMe�rts[m[N*r�e � Y �'�—�' �j}��— aooa�ss Q COfI�lOC10� � O01R � " ' DISiRICT NO. GROU� MAv FROCESSED BY V CITY . El. BK iG Z �0 I om exempl onder Sec. � ' of ihe L.A.Co. uf aNg NO. � ciA55 �J � ... . .� .� r+o. DESCRIPTIONOFWORK- fEE � V Plumbing Code and/or Sec. � of the viNn� IqUSf SfWEN CONNKfING TO r� DAiE VALI ATION W � - � B.B P.Code for ihe following reason � Puauc SFMa � ��'/��/�'�i y . SE IC IANI(,SEEGAGE PIT OR f1N41 Z iiTS AND/pp pqqINF1EL� . . DOfB � 1pU5E SEWER CONNFCiING TO BY PRiypiE DISPOSItI SYSTEM -S�gnarure � ca+nrtct�oo�nor.ini�oc.ox � , �� - - OWNER-BUILDER DECIARATION `�+oa�c 70�+ou5e sewea . }.�.�reby affirm ihat I am exampt from the CoNmctor's license � e�N.��E55 ooi.�ortPvJffitA�N�ae � " ( �t for the following�eason(SCCIOII 7O3I.S,BUISfIQ52 dOd Pf0- lLLTfN.NEPA14 pR ABANDpN MOUSE - • � ..aSiDnS COde�; , SEWEF OR OiSPOSAI SVSTfM . . . .. . , � ' ... ��^.� L�L A ❑I,as owner of the property,or my employees with wages as �p�• •1 O their sole compensation,will do the work a�d the strocture � � � �' . ' �� � � - - ' is not intended or offerad for sale(Saction 7044,Business �'�,. C ond Professions Code). OWNER�S � PB�mii f � �n . . � .L 7...� . ❑I,as owner of�he property,am exclusively contmcting wi�h AUTHORIZATION TOTA�FEE � �(� '. y • �c 7�5�i� licensed conn«tors to construct the�JlO�BCi�S9C110��040, -� � I HAVE Ai THIS�AiE A CONTNACT WITH TNE HEREiN NAMED CONiRACiOR 70 . �� � � BUSIf1065 OII(J PfOIC5510f15 CO(IE�. CONNECT THE ABOVE�ESCRIBED E%ISiING DWEIIING iOTHE WlIIC SE'NFR. ' ^f1�C`p L CONSTRUCTION LEN�ING AGENCY� . �� � �� .. . _ _ ai o. � u u I hareby affirm that Ihere is a construUion lending agency SiGNEDTHIS DAYOF � l9_ � . for ihe performbnce of the work for which ihis permit is ' � �'NEpOn ' ,. . . i5SU9lI�SlC..3097�CiV.C.�. OwNERSAGEM . AD�RESS lander's Nome �� � �- � � ��� Lender's Addresa . . � � � . '- . . .. . .. . .....- I certify ihot I have reod this opplication and sta�e that the � � � above informotion is mrract.I aqree to[omply with oll County - � �- � - � � � . ' � --- - � ordinooces and Sta�e laws regula�ing Piumbing and Sewers, - ' � and here6y authorize represenranves of this County to enter �� � - � �� � - �- . � � � � �- �� � � ypqq,th}�qFjo meroioned property for insp�ctpp,pu/p�y_es ,. . . . . . . . . . A�.1� D�I r�� O J 1 O 00 _ah JJ.�..�,1�. Signofure of Permivee Dale - SFE REVERSE FOR E7(PIANATORY LANGUAGE �, - iNsreeroR�s Mores OWNER-HUII.DER DECLARATION APPROVALS onrz inuvEaars s�c�wrurzE � � I hereby affirm thn�I am ezempc ftom the Contrector's r,�,���R , _ , License[sw for the follo�ving reaon(Sectiow 7031.5, . ... � . . - Bwiweu miil,RuJusio�s Codik Awy eiry or corsey aoer+[crrnoitroN�t.- - . __. . . ._:_- . . �wbicb.'reqYins u pnrwlt w co*rl►reR�lter.Gnprous. euuon+c ort womc .- �-� --: � .� .. ... : . . . •�'� .,i���dawroHsb.or raPair asy sMrtbra.Prlor to!ct Ja�wwce. �i�oa'a��inTls) . . . . . .- - _. . . _._ .._ . -__..- . . . _. . . �slso seqµirvs eba applicowt for srcb p�nritt to file a ':�, • ....,'� . ,.. �. .� . rigaed statwwe�t SMt!w 4 liae�tt�d pan�wwt ta tbe � �s.woot O� atvweu O .. .. .-. . _ . . ... . ,� ;. . - � ..prouuio■r oj tLa Contracto�r Llcyw law(Cbapfer 9 ALTFR.IIFPAIR.SEWfR OR . � . . . .. (COlronfeMCiMg tU1l/l$iCliOlt ]�OI�DIV�t101'3 of iba SEWAGE DISPOSAl5Y5iF/A . . . . Butiwatc and ProJissiowj Codol or tbat be ia exempt ��u sEw a � . : _ .. . . . . ... .. - .tbereJroni atid tbe bm&Jor sb�all�ged wwMptior.Awy � s�ariu sEvric ra+us p � . +»olatiow oJSeceio�703I.5 by awy aypliaewt jor a pmnJ! sttr.nt O cessvoo�s p � - � ' �subjects tbe appJitawt w a ntvll peMaJty oj wot inore tbaM . __ ..- ... .. ,. ..., .. ,_ . .._ _ . . . . . .. . .___ .." . � : , , ,�.. .�- . jive buwdred da1lon(�5001.: . . I " . , - ❑i,ec tbe awnec of the ptopetty w121 do the ma'�sad � � � ' � � _.. � '�the sttucture ic aot ioteeded or ot&rcd for n�e: , , ; . . . .. .... _..._. �- _� _ . _ , < ', (Sea 7044.Bwsiwou mid Aafsuio�r C«!c Tti�Car '+ . .. . _. _. ._. . _ .. .�_ � -- - - - . . - _ ....� _ . . tractor's L'ueu�Lau�do+s wot qppiy ro as omw�r oJ . � ., ._ . - � pso�rty wbo brJJdr or imyrowr tb�ato�,ard wbo does � .. . . . . . � --- . --- sacb,00rk binu.lJ prov:drd tbse a�el,lw.prov�n,swts � . �.•' . . are rot Iwteiided or o/farnl for.ml�.I/,bomewr,tbe k �. _ . . .. .� . ........ _ . ... . . . . '. � . ,-..:.. � . . �, . . . :.bwJdiqg or bs�oueisa�t ir soN witbiw aw ywr of � . . . . .. - .-. . _ . . � , . eornPleNuw, tb� own�nbrJld�r wiU ba+� ibr brrJow i � . .. . -�.��oJ prooi*8 tbat b�did wot brlld or irsprovr Jor sbe ..__ . . ... _ �. . . . . . -- --___ __. .. _ . . ._ . . . .. . . . ,.. ,. _ . , parpore oJrali.l. - _ _ ' ' • : : �:.. .. I am exempc nader Sec. . , . � � - . B 8r P.C.far this reasom � '�_ 1_ � _ _ , . . �-� _ Date ` - - -. . _ _ _ . . ♦ Owner _ INSPEROR'S NOTES . � � . . . . . � � , ,� � . � � � � -` , ' '�1 I _. . _ .. . �. �1�' �'. . �