HomeMy WebLinkAbout1257A WORKERS'COMPENSATION DECtARAiION �
I hereby offirm thnt I have a certificate of consant to salf
insure,or o cenificme of Workers'Compensa�ion Insuronce,or �ena/ao
o�e.r;#�.� � e��38 ,La6 C.) CE BOB(REV 8/BI) APPLICATION FOR PERMIT
Pou�YWK$���i���pany�remont indemnity �, _
❑Certified mpy�s hareby furnished. - SEWER - SEWAGE DISPOSAL �
�Ce�rified copy is F�led with rhe county b ilding inspecYon 530//C�, COUNTY OF�OS AMGELES BUILOING A(dD SAFE7Y
depa�lment. 1
Dare�3_j_�$bpplican� POR APPLICANT TO Flll IN CONNECTION DATA
CERTIFICATE DF EXEMPT�ON FROM WDRKERS' eunoiNe �-
COMPENSAiION INSURANCE- noo2e s sinrior� oevn� ,
(TMis eection nted not bt rompleted if ihe wtlik in0otved by 1he MANHOIE REFERFNCE UPPER
permi�is(or one hundred dollarc(SI00)or lesa.) tocnim Diamond Bar - �o�„ER
I certify tMt in the performance of the wwk for which this ��ST GO en Springs Carpio Tr��CONNFCTION IFNGTMFROM
Y. CUNB P.L. M.L TO P.L.
permi�is issued,1 shatl no�employ any person in any mon�er p�� ��,�
so os�o bemme subject�o�he Workeri Compensafion Laws. �,�R ca��u no. �os No.
��� iftUNKPERNJTND. ROADffRM1TN0.
Date Applimnt nooaess 10 4 Park View DY.
AFFIDAYIT WAIVER EASEMENf RECORD MSTR NO. OATE
'fiCE TO APPLlCAM: If, after making ihis Certifica�a of �r Covina � E,. � -9541
}mption, yao shauld 6ecame sub�e[t fo 1he Workers' tEGA�
Compenaafion provisions of fhe Labor mde,you most fonhwith DESCRIPTION �OT*D.� � � HWy.pp ST.WIDENING
comply with such p�ovisions or this permi�shnll be deemed
re�oked. moa TRAC SiATf ENCRpACNMENT
i10EN5ED CONTRRCTORS DECtARATION -� '- ^i°.°F�°r,s. v�RMit N°.
SIZEOf LO7 NOW ON LOT
I here6y affirm ihat I am licensed under provisions of Chapter �5E OF
D(commencinq wilh Section 7000)of Division 3 of fhe Busi- em�dr�s Residential anac.�s
ness ond Profeuions Code,a�d my iicense ia in full force ond r
l�ffOCf. -- - CONTRAROR R.C.R. P lumb ing� t�C. CONNECTION CHARGE FEE �
License Number �'�L l.7 Q Lic.Class .� agno La. Ve. BEIMBURSEMENi FEE 6
�� -C—� AOORE55 Q
Comrac��('.R PT.TTMR7Nf:Dare �']�I / f� - DISTRIRPq. GRDUP n,av �ROCESSEDBY U
I�f� /�y CITY TEL NO. �� �K � O
STAR IIC.
I am exempf under Set. nf the l.A.Ca ucENse rJo. 0.�ss
Na. DESCRiPTiON Of WORK FEE G
PlumbingCodeand/or5ec. ofthe FiNAt VA!lDATION W
HJUSE SEWER CONNEQING LO /� � OATE
PVBIIC SEWER
8.8 P.Code for the following reason gp�K�q�,p�,�Epp�p�T�p ` FiNA� 2
PITS AND/OR DRAINflELD
DOfe FqUSE SEWER CONNECTING TO AY
VRiVATE pi${bSAi STSRM
$i9nafU�2 CONNER AWITIpNAI BLDG.OR �
OWNER-BUILDER DECLARATION �M1^7RK TO HOUSE SEWEF
OVERFtOW$EEGAGF PIT,pRAINFIElO
''�greby aHirm that I am exempl from the Con�roc�or's License FXTtJ,CESSPOOL,�RYWELL.MANHOLE
g far the following reason(Se[}On 7031.5,BU�SnC55 Oltd Pf0- AITER,REPAIR OR ABANDON MWSE
t c551ons Code�: SEWER OR DISPOSAt SVSTEM _ � ����
❑I,as owner of ihe properfy,or my employees wifh wages as �
their sole compensation,will do the work and the st�ucmre i'• •• ' � 'J
is no�intended or affered for sale(Se�lion 70dd,8usiness
and Piofess�ons Code). OWNER'S Permit S Q Q J.w o�j,5�i
❑I,as owner of ihe property,am exclusively mntraUing with AUTH�RIZATI�N TOTAL FfE y -
licensed contracrors ro construct the projec/(Secfion 7Q44� 1 HAVE AT iH15 OAiE A COMRACT WITH THE HEREIN NlNAEO CO TRAC70R i0 � �- ������`
Business and P�ofessions Code). tONNECi iHE neovt oEscaieEo ExiSt�rv�ow[wnG 10 iH[weuC sEwEk.
CONSTRIJCTION LENDING AGENCY '�'?r r�h
I hereby a$irm fhat there is a construction lending agency 51GNEDTH15 DAYOF 19_ �
for the performante of the work for which Ihis parmil is �R OR
issued(Sec 3097,Civ.C.). owr�rts nc.�NT
AOORE55
tender's Name
Lender's Addroes
I ceTlify ihot I have read ihiz application and state ihat the
above information is correct.i ogree to comply wiih all County
ordinances ond State laws regula�ing Plombing and Sewers,
and hereby authorize representatives of this Coumy m enter
upon the abovi -meniioned prop ny for inspection p�rposes.
RCR BY; �p��,,.,P �,�, 7 31 86
Signafure o�rmittee Dote SEE REVERSE WR EXYLANATOAY LAMGIlAGE
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