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Home My WebLink About7453A (19)WORKERS' 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 copy thereof (Sec. 3800, Lob C.) Policy No.61WBRK4 &4pony Hartfnrd C7rnirn Certified copy is hereby furnished. Certified copy is filed with the county building inspection d tm t. Dote Applicant CERT FICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE This section need not be completed if The work involved by the permit is for one hundred dollars (11100) or less.) I certify that in the performance of the work for which this permit is issued, I sholl not employ any person in any manner so as to become subject to the Workers' Compensation Laws. Date Applicant CONNECTION DATA NOTICE TO APPLICANT: If, after making this Certificate of STATION Exemption, you should become subject to the Workers' LOCALITY Diamond Bar r nsoiion provisions of the Labor code, you must forthwith UPPER L R i ., ly with such provisions or this permit shall be deemed TYPE OF CONNECTION revoked. CROSS ST g LICENSED CONTRACTORS DECLARATION P L. ML Ta P L. I hereby offirm that I am licensed under provisions of Chapter CO IMP. NO. 9 (commencing with Section 7000) of Division 3 of the Busi. MAIL 3151 Airway Ave. Ste. N ness and Professions Code, and my license is in full force and ROAD PERMIT NO effect. License Number 409610 Li, Class B Costa ContractorBramalea CA Dare 1 am exempt under Sec. of the L.A. Co. Plumbing Code and/or Sec. of the B. B P. Code for the following reason DESCRIPTION LOT NO Dote Signature STATE iNCROACi WNT OWNER-BUILDE DECLARATION NO Or SLOGS. I hereby affirm that I am exempt from the Contractor's lice Low for the following reason (Sectcn 7031.5, Buisness o o- Ia-dons Code): toD`NGS none as owner of the property, or my emplayees with wages as their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business CONTRAc1oRBramalea Calif. Inc. and Professions Code). I, as owner of the property, am exclusively contracting with REIMBURSEMENT FEE licensed contractors to construct the project (Section 70", Business and Professions Code). MAP PROCESSED eY CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency CENSE No 409610 CLASS B for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). FINAL Lender's Nome Toronto Dominion Bank HOUSE S RR CONNECTING TO I D UU San Francisco VALIDATIOA Lender s Address FNPI I certify That I have read this application and state that the Pn5 AND/OR DRAINFIELD HOUSE SEWER G TO above information is correct. 1 agree to comply with all County ordinances and Stole laws regulating Plumbing and Sewers, and hereby authorize representatives of this County to enter CONNECT ADDITIONAL 9LOG OR WORK TO HOUSE SEWER upon the above-mentioned property for inspection urposes. A-, rSignature of Permittee Joe ALTER. REPAIR OR ASANDaN HOUSE T6P6+:O CE 9e3.REV 1153; APPLICATION FOR PERMIT SEWER - SEWAGE DISPOSAL COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL IN CONNECTION DATA e%IID NG ADDRESS STATION DEPTH LOCALITY Diamond Bar MANHOLE REFERENCE UPPER L R NEAREST Grand Ave. & Summit Ridge Dr. TYPE OF CONNECTION LING i"FROM CROSS ST g Y. CURB P L. ML Ta P L. OWNER Bramalea ltd. CO IMP. NO. c No 03- 1 - X)e FEa MAIL 3151 Airway Ave. Ste. N TRUNK PERMIT NO ROAD PERMIT NOADDRESS Costa ANIDAVII WAIVER EASEMENT RECORD INSTR NO DATE CITY MesaTEt.NO (714)850-1001 LEGAL 36DESCRIPTIONLOTNO HWY OR ST WIDENING 42 STATE iNCROACi WNT NO Or SLOGS. PERMIT IZ SIZE OF LOT NOW ON LOT toD`NGS none BARGES CONTRAc1oRBramalea Calif. Inc. CONNECTION CHARGE FEE ADDRESS 3151 Airway Ave. N REIMBURSEMENT FEE DISiRICr NO GROUP MAP PROCESSED eY CITY TEl.NO STA BK CENSE No 409610 CLASS B NO DESCRIPTION OF WORK FEE FINAL HOUSE S RR CONNECTING TO I D UU DATE VALIDATIOA PUSEPTIC TANK, SEEPAGE PIT OR FNPIPn5AND/OR DRAINFIELD HOUSE SEWER G TO Br XrCTI PRIVATE DI SYSTEM CONNECT ADDITIONAL 9LOG OR WORK TO HOUSE SEWER RFIOW EPAGE PIT, DLFA=,EID EXLN CESSPOOL. DRYWELI NJ.NHair ALTER. REPAIR OR ASANDaN HOUSE Jf 5 3 ASEWERORD+SPOSAt SYSTEM 10 IF r'7 OWNER'S Permil s 50 AUTHORIZATION TOTAL FEE Z G HAVE AT THIS DATE A CCINTRACT WI'H THE HEREIN NAMED COPnRACTOR IO CONNECT THE ABOVE DESCR:BED EX!SHNG D'M 111Ni ip THF PUBLIC SE'R'ER / SIGNEDTHIS DAY OF 1q„-F , OWNER OR OWNERS AGEIM1i ADDRESS EEE REVERSE FOR EXPLANATORY LANGUAGE 0i13-86 I 1 ji IU!1 jLn I N GNI i I