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HomeMy WebLinkAbout1236A WORKERS'COMPENSATION DECIARATION . � � I here6y affirm that I have o certifitote of consent ro ulf � . . � insure,ar.a certificote of Workers'Compansotfon Inso�ance,or. . 7anaaso o�e„�f���Yb�a�a�f(e.38o�,r�ont zndemnity ��`R".B�B'-' APPUCATION FOR PERMIT Policy N . � �� ❑Certified copy is hereby forniahed. � � �� . � . _ � . .- . . . . SEWER - SEWAGE DISPOSAL - � - � � � �Cartifed copy is filed wiih ihe coonry b ikling��s�ro� 5 30/.T,� �OUNTV OF L�5 ANGELES BUIlO1NG AND SAFETY - de�9��^i�{7�/86 . �RCR By . . oa�e /+ppNcam _ FOR APPLICANT TO FILL IN CONNECTION DATA �. � � CERTIFICCOMPENSATION INSURANCE RKERS' . �� 2443y E. CiOld OlIIt p�.aCE'. � � STATION ' DFFiH (Thia section need nat be tomple�ed if the work involved 6y the Diamond Bar M1MMMOIE RlRFRENCE �� �� - VPPER permit b for.one hundred dollan(i100)or leas.) � . LO���T� � ° � PFAREST . TYFE OL CONNECf�ON IENGiN FROM � I tertify tFat in the perfoimonce of the work for which this �Rp$55T. Y. CURB V.l. M.I.TOP.t. permi�is iuued,I sholl not employ any peraon in a�y manner . ' w os lo become subject fo Ihe Workeri Compenwtion Laws. OwrvFn CO.IMi.NO. - lOB o. Q �-(�j , � DOIE APPIitOl1� � . . . . . �E55 P.O. BOX 3327 � TRUNKPFRM11N0. ROADPFRMITNO. . . . ... /�TICE TO APPUCANTi If, after makin this Cerlifimle or � Covina -y67-9541 A°fio�vir warvia [nSemeNr RE�pRO.INSTR.Np. DATE f . 9 CITV 1.N0.' � ;Jnprion,� you should become subjec� �o the Workers' i��� Compenaa�ion provisions of ihe labor code,you muat forthwitb oEscaimiora tot HWY.pR 5T,WIDEMNG �toreply with wch provisions or�his perm�r shall�be deemed . . . � � lBVOI[ed. � " � � ' . &OCK TRACT STATE ENCROACHMENT . � � �- UCENSEO�CONTRACTORSDECIARATION ReS�d2Tl �°°&�5� �RMiTrq. . I here6y affi.m that I om licensed under provislons of Chapter SrzeoFiot woNio* � 9 commentin wirh$ettion 7000 �of�Division 3 of the Busi- �� ( lJ � BUIIDINGS CMARGES � oess ond Pro4eulons Code,and my licease is in full force and .. . � effact 3364Z8 , C—j6 CONTRACfOF CONNECTIONCHARGfFfE ' d l�cense Nur�e���c.CI�SLI.G1(iL_� ' ' qpp� ' � � REIMBURSEMfNT fEE � /1V�UV • co���p�to� oa�s ��TY 336428 �E��' C-36 ��5,"�R"°. °��` ,,�o AtOCF55EDBV u � � � z ❑I am ezempr undar Ssc. - of the L.A.Co. iiceNsc No. � �cinss 1� � NO. DESCRIPTIONOFWORK iEE Plumbing Cade and/or Sec. of fhe ���,�Q����ii�TO . . . /� .�� DATE� ��y'�/�t VALIDA ION . n W&I $EWpR B.8 P.Code for the following reaaoo � � it�Awc,s�EP�cc Rt oa FiNA� "' ? wn nrJoroR a+n�r��e�o Dote � Fqusc sEweR coniNecnNc ro B� PRNATE 0 V TEM � Signarure cOWN[ci noDinqwt eto(i.prt � � � ,� � � OWNER-BUILDER DECLARATION � �"o°K To�ousc s�w[R � j.beroby affirm that I am exemp�trom tha Contracfoi s license [�x��rN��Ess�roPoi.�ortv��.'ve°iRiA��nNo� . . .. . . . T for the following reoson�SOCtO11 7O3�.S,BUISOB55 Otld P!O- AIfER,REPAIR OR AMNDON 110USE . .SiO(ti COfIe�: SEWER OR D�Sf`(JSAL SYSTEM , _ ,, . _ .`�t r�Z.�n 1 G J IY ❑I,as owner of the properly,or my employeas with woges as - their sole compensmion,will do Ihe work ond the structure - � - � - �j.r a.e � � is not iniended o�offered fo�sale(SeUion 7044,Business and Professions Code). OWNER'S Pe�mit S �(j d _ �A.o.2�,5 Q ❑I,as owner of rhe property,om eaclusively comracting wi�h AUTHORIZATION TOTAL FEE C S licensed coniractors lo cons�ruct the p�oject(Section 70G4� � I HAVE AT 7H15 pATE A CONTkACi WITN iMf HEREiN NFfAED CONiRACTOR 10 � ' �p�C�'J O U BUSif19b4 OfIfI PfOfBSSiOf15 COCIBJ. � CONNfCT THE ABOYE PESCRIBED EkI511NG DWEIIING TO THE PU&IC SEWER. � , _a^^5... C L CONSTRUCTION IENDING AGENCY � � � � � - � � �"� �� , 1 hereby offirm thol Ihere is a mnstr�ction landing agency SIGNEDTHiS �AYOF 19_ ', . for fhe parformaace af fhe work for which thls permit Is � �'�R� - -- � '� ISSUld(SBC.��,CIV.C.�. OWNERSAGENT ADDRE55 Lender's Name � � � Lender's Address � � . . . . .. . ... .. . .. 1 certify that I have read this application and sta�e Ihat the � � � above informolion ia to�rect.1 aqree to comply with oll County - � �- ' � � � '- � � . � � � � �� � ord�noncas ond Stote laws ra9ulating Pl�mbing a�d Sewers, . and hereby authorize reprosenra�rves o(this County to enbr . � � - � � - � - � � - � uponlhe,q�vp-mantioned propeny for Inspepiiqq pu�pgsps. � � icGli n T1�`��� O/10(UO �� Signature of Permiftee � .Date . SEF REVERSE FOR EXPLANATORY UNGUAGE � � " � � ' � � �� INSPECTOR�s NOTEs �� . �- OWNER•BUII.DBR DECLARATION APPROVAIS onr�.• .iNsvEcroa•s s;cruTuaE. - . . . . .. . I hereby effitm tlut I am e:empt from the Contnctor's . p�y,,���a . 3 _..... :_� ... .. - License Law for the followtag reamn(S�rrtiow 7031.5. ��` � � Bwiwesc and Profenions Co�de):Awy dty or roawey su�ortM�a.�c�. . .---.. . . . � � .. . . � � � � �� ' wbicb frvgnins a p.nwte to cowsbwc/,�alter,&nprocw� , , � . . .. . � , � .�� '�� drnielitb,or rapair awy sfrreMre,prlor to iis lnraece. YDIICTANK.SFFP.%T�S)_._._ �Nniatawr�ietn - --._.. . ...._ _ . - - '-'.._. .. . .._. .... _... _... .___ _.., . a&o ragrirvs.tbo-opplJeaMt Jor areb pennit W jile a � assroo�❑ -oRvwEu O... . . . . �. . . , �.� . .,. sigsed swa,.w.r rbar b�&lk�ws�d purrrawt w tbe � .. � pro�ririo�r oJ tb Cwtrnceor's Licv�ur Low(Cba�ter 9 _ K7EY.REYAIR.'NER OR _ . . . ... . _ •. .. ..... .... ... ICOII{MMCIKB.WIfG SICbDII 700019�DivisJow 3 oj 1be gM1AGE DISPOLLL SYSTEM �NOVSESfWEN . . _ . _-- . ' '_ .. . . � , . �l118SL OI/d�fY�12[%04[COd/�M SbAf 11P�[6Y@MIp( �. , e�cxsM�serrK rnwcs❑ � � :. . . . : :... .,.. .� , ' . . . . violati�ow oJs�ecb'�on��bY Y��aaws�tias.Ar� �, 94v.vrt s O eessvoois❑ � --- _. .. . . ..... .. •.. --.�., .. �.. . '. ...�... rabj�cts tbe applicswt ta a cioil prwalty of wot aiore tba+r . . ...: . . .�� /iue bardred doAan(iS00�: -, _ _ -- : ❑I,ac the ow�ner o{the propertp sill do dx wa`�.and , . �.�� ; ... .- . � . � ,.,� .-..�-..-`.� . _ � . the atruttnce is not intended or oHered for uk: � , ..... _.. . - . . : . " ,.� _ - '� �� (Sec. 7044.Brrisas md Rv/eerroas Cod�:Tb�Cow. . � .. . ...... ....� .... . .. . . . - .. . . . hxeori LJcews�L�w doer twt apply to aw oro�er oJ . ... .._ . ._ . ._ . . � property wbo brtWr or&wprowr tb�nas,mid wbo doa . �-- . . . --- . .. . ._. . — . '.� � .,,... . sut6 wor�i binua�prouid�d tbaf arcb uonprnw,xcnb . . . ..are�ot iwteMdd or oJfew!for.td�.lf,.bo'urtrer,ibe [ _ . . . . .. .... . _. .. __. . . . ._ . , . ,, _ . . . ., � : bdildiwg or-:lw�oa�wt.&iold taitbiw ow�y�er of __ __... .. ___. ' ' conaplediow, tlx ow�er8uild�r wiJJ baH !be iwdsn ,:: M D�aB tbot b.dN aoe brild or impronv jw ctx _ . . ._.- ..___ ,.: _, f+���ol�l. . ,. . :. ,... , _ _ . _.._ - _ _ I am eaempt ander 5ec. _ , ,: , _ _ _ _. - B&P.C.for this zeason ,.� I __ i --� . ... Date , , _ Ovvner i INSPEROR'S NOTFS - . . . .. " . � . .. . - � � , � . � . , :y�� ':1'.'�. ...�