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HomeMy WebLinkAbout1234A (6) WORKERS'COMPENSATION DECIARATION � � ' � I heroby affirm that 1 Fave a ceriifica�e of consent to self � � insure,or a ceAiFitota of Workers'Companaolio�Inwwace,or .. ��'�T� � - . �. ' '� Polty{�2��y3`'�1�`����reinont �nde�ity ; . �;°�'R`°.°�e" �� - : ApPLICATION F�R PERMIT , , y❑-�Cerliffed copy is hereby furniahed. - . . . _ .. . SEWE� - SBWAGE DISPOSAL � � �� � � �- , •Ll�Cenified copy is f�ied with ttie counry aildinq��5��o� - . ygp� COUNTY OF l05 ANGELES � BUILDING AND SAfETY d�r��Rf��25d RCiK B��� oo�e Appiicom � FOR APPLICANT TO FILL IN CONNECTION DATA � CERTIFICATE Oi E%EMPTION FFtOM WORKERS' y,ntpniG � - � -� COMVENSA110N INSURANCE � .. noowEss 24450 �;. �i'O1C� oint Place STAr�°N -� � � cevtH- � (This section need not be comple�ed if the work lavolved by�he i�e,�iTv Diamond Bar � ���«E�fEQ� � � . . . °°PER � permi�is{or one hundred dolbrs(f(00J or less.) _. R i I cer�if tho�in the rformance-of Ihe work for which this �"�sT , rrreoFcoNrrtcrroa ¢r.�TMF�. � - Y P� CAO55 ST. Y. CURE P.l. M.L.TO P.l. � : .permit is issued,I aholl nm employ any perxoa in ony manner . 1 sa as to 6xome su6ject to the Wvrkari Compensation Laws. ov,,NER CO.i'nv.NO. � � i�oe r o. ��d�3 � � ; Date Appliconl l n�'4o�o`�ss P.0. BoX 3 3 2 y ra�nnc venM�r r,o aowo Rvµir no. �. �ICE TO ApPIICANT: If, afier�makinq ihis [ertificate Of� ��Ty- C�VinB l�s-967-y541 AFFIDAVIT W�IVER EASEMENT NECONO.INSiR.NO. DAR � .mplion, you should'6ecoma subjact fo�the Workeri i�A� Compenm��on prov�a�ons oflhe Labor code,yw must forthwith� �� orscevriora io HWV.OR ST.WiDFNING � compty with euch provisions or lhis permii shall be deemed � I ' �pVOkQd. � � � � BLOCK TR STATE ENCFOACMh1ENT LICENSED CONTRACTORS DECLARATION �pM�T�� Bl SiZf Of lOt � ON LOi � � I hereby offi�m��hat I am I�censed onder provisiona oi Chap�er �� � � � 9(commenting with Section 7000)of Division 3 of Iha BU51- BUILQINGS Residential � ��Q�s ness ond Profeaaions Code,aad my license is in foll force and. ""°". ' 33 b 4 2 ts C-j 6 CONTRACTOR CONNFCTIpN CNARGE FEE { lica�se N lic. � - Ap�u � ' REIMBU45EMENi F(E } 1�C�#�A�a `���6�fr- c i . . . bISiR1�7 Np.� GROUP �. MAp PRO�E$SEO BY V COnhOC�Of Opl! CITY • iEI.N BK W O ❑I am enampt under Sec. � af ihe L.A.Co. u�7ri5[NO. [i 55 ' l� ' � PlumbingCodeand/orSec. oNhe N�� DFSCRIPTIpNOFWORK ifE � HNq� V � �Ms���Rcora�cru.�To �� �� DATE ��/�-/�� VALIDATION Q 'i �� B.B P.Code for the following reason y ic uNk,stcr�tst art ok ��NA� Z I . � WTSANDiDRDR�INF1El0 Dale HOUSE SEWER CONNECfING TO gV b � VkNAi D1 51'S M � ' Signature cO,+r�eCt nooi*roNsi e�p�.qt . . . � . i � � OWNER-BUILDER DECIARATtON wanc ro Hovs�s�wee OVERFIOW$EEOA('f pl,64AINFIFID r 1.mere6y affirm ihot I am exempt from�he Caniracror's Liceme E%TN..CE550.")Ol.ORYVYEII e+wwHoie � ' , . . � . . � . for the following reasoo(Secton 7031.5,Buisness and Pro- urtrt,qEnAiR on nanaoow Hous[ _ . - ' �"� G�j,4� . .sians Code): se'ncv at orsnosr�t srsrvn , . _ , . , i j ❑I,as owner oF Ihe propany,or my employees wifh woges as �• •.� �• i O � their sole compansation,will do�he work and the strutture � ' � � is not inlended or offerad for sole�Secllon 70M,Business � + e z 7,5 Q a�d Pmfess�ons Code). OWNER�S Permit S /Q ` ❑1,as owner of the property,am exdusive�y contratting with AUTHORI2ATION TOTAL FEE � Q � . . • o.o`z'],j�� licensed contractors to co�strucf the(JfO�eC1($ectiOn 7044� 1 NAYE AT iM15 DATE A CONTNAGi WITM TM HEREM NAN4D CONTAAQOR TO � � � � - � � BUSil1035 Ond PfOfE55i0(19 COfJC�. C0�INECT iME R60VE GESCRIBFO f%ISTING DWFl11NG TO TM PUBIIC SEWFR. . Q&'.�5.-Ej 6 : CONSTRUCTION LENDING AGENCY � � - � � ' � , �' � I hera6y affirm thot the�e is a construttion lending agency SIGiVEDTNIS OAYOf 19_ � � for the performance.of the wo�k far which this permit is �����NT � � � � - � � � � �- � � , issued(Sea 3097,Civ.C.J. � - � '. ' � . AWNE55 ., . . . lender's Name , Lender's Addreas . . � . . . � .. . � . . . . . . I cenify Iha�I have read this opplication and slale tho�the � ' � � above information is torratt.I ogree to comply with all County _ - � . ' - . � � --�� � ' o�dinances and Stofe laws reguloting Plumbing ond Sewers, . . I � and heroby outhorize rep�asentotives of this Counry to enter . � . � ' � � �. � - - -� - � - I rVAqq Ihr qb e�mentioned pr erly for inspecJipry_py�yQses. , , . � , RC.LC ISy O(10700 � ; � ��..Q_I.�:�o �� Signoture of Parmitfae Dole SEE REVERSE PoQ EXPIANATORY LANGUAGF � - l ' INSPEROR'S NOTES OWNER-BUII.DHR DECLARATION � APPROVALS �T� wsxcrow•ss�cNArurse . .. . � . ., IherebyeHitmthatlamesemptfromt6eCaetrattor'� ����a . , Licenee I.aw tor the followiog reswn(SseNow 7031.3, Ni . . . ::.r '�. B.sins.ss�ad Anjtuio+.r Cad./:Awy c7ry or coreey ' oow.[a�oort+orHt . . , �. . - . - . . , , .'. :.' . � .., � ,�.wbiou,.. ..., o p�nnit to cow�trsrt.t7tp,irnQrow � lu�dr+o oa woaK . . .. � � � . der.iolfxb, ro* e/w�r asy:tnu�d�n.Prwr Jo ftc irarencr, ' semctuac.s�o.vyr�s� aho rirss-tb. t areb �t ro /1e a .vmiov own.��to � - --� - .....�. . . . .. . .._.- . .... �,��',. ' sig��stabrrowt��sd�nrowt w tba , asscoo�p � oRvweu p . ...- ... � ' � ' , � � . .' prouiaio'u of tbe CowdnetorY Llceiuo Law(Cbeptsr 9 x�,wrsuo stw¢R ors . . . � ' . . . . (ro/n�arciwg wleb SecNow 70001 01 Diviuow 3 0/1ba stw�ct nis�srsrs�n . . p4CONNECI RW AND . . . . SYpfIBu med Projwiaaf Cod�J w tlwt bs Jr arrmpt - we�Noow�avsc sewca . - . . . . tberoJronr n�vd tbe b�a�is for tb��d as�peios.Aey y�aFu��vsKT,yx3p � ... . .�. .�..._.. a�iaJaaowo/SecNon7031.Sbyasyapplin�tforepenritt mr.vrt O Cessroots p - . _ � ..-. _. .� - .. ... . .. :.' '•.�...._:. subjects ibe appli�awt to a oiuAP�ndh'o/wot iaare tbaw , _ .i;, Jioe brwdred doJlwr(J100j: _— _ _. ;.,: 1,as the awmer of the ptopvty ivill do tLe wc-••.and . , . .-._.. ' . .._.. . . . . � the structure ic not fotended or oHeted for aa1e. � ._. _ .. .. . � :. . . . ...- . �.c. (Sec. 7044.Bwi�au ard Projttrlowr Codu T6v-Cow- .. . , �---.._. . . . _ .. .._ ...- . . tractor's.Licvun Lxv do�s fwt a�p/y b w oto��r aj . - _ _ . _ .. . _. .;.., -. -. ,.. . . . P*opersy wbo buildr or iniprowr tboro�,awd wba does . ._.. _ .. . _ . . . .- . .. rrxb+oor�L bbae��I proaWid t6at areb troprovea�aw# , ' � � �.a.e wot t�+teaded w aJ/'ered joi ade..(/,bou+ewr,tbe �-- - - . . . .. ... . bxiJdi+rg or improwmert h soJd wilbiw o�u yoar oj . .. ._ �- . -. ... . .. .._. . . . . . ��.�:���-. _.: . '�� . rornpktiow. tbr ov�renbrlWa�uiU Iww tbe bmd�w � ' � oJ.proviNg ibat be dld wot br1/d or lmprotx jor elx _ parpose ojsal�.J . . _ , , _. __ . ._ , . _ . , - I ffID e7tempt untier$0[. , _ .__�, : `i . _ : B&P.C.for this resaon -" . . .� - Date _ Osvner �.. � iNSPEtTOR'S NOTES - � � � � ' . t � . _. .. . _ � �. i . ' � .