HomeMy WebLinkAbout1496A (8)WORKERS' COMPENSATION DECLARATION
I hereby affirm that 1 have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, or
o certified copy thereof (Sec. 3800, Lob C.)
Policy No. Compony
r❑ Certified copy is hereby furnished.
l_7 Certified copy is filed with the county building inspection
c.1eeP4fa%6 Apphaam Van Diest & Son
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the work involved by the
permit is for one, hundred dollars ($100) or less. )
I certify that in the performance of the work for which this
permit is issued, 1 shall not employ any person in any manner
so as to become subject to the Workers Compensation Laws.
Dote Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of Ike Labor code, you must forthwith
cf dy with such provisions or this permit shall be deemed
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and
effect.
License Number 376814 Lic. Class C 42
Contractor Van Diest Dote 4//4//86
❑ I am exempt under Sec. of the L.A. Co.
Plumbing Code and/or Sec.
B. 8 P. Code for the following reason
Date
OWNER -BUILDER DECLARATION
I hereby affirm that t am exempt from the Contractor's license
Low for the following reason (Secton 7031.5, Buisness and Pro-
fessions Code):
n 1. as owner of the property, or my employees with wages as
eir sole compensation, will do the work and the structure
\ - not intended ar offered for sale (Section 7044, Business
and Professions Code).
❑ 1, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Section 7044,
Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued (Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify that 1 have read this application and state that the
above Information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upon t&VI ove-mentionhf property for inspection purposes.
76A612D
CE 608 (REV. 1189) APPLICATION R PERMIT
SEWER - SEWAGE ISPOSAL
C LINTY OF LOS ANGELE BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
DATA
ADDRESS 21028 & Mall Ibm Dr.
/-CONNECTION
STATION �. -l�� DEPTH
�/
LOCALITY Diamond Bar
MANHOLE REFERENCE UPPER
64
CROMNEAREST
CROSS BT
TYPE OF CONNECTI LENGTH FROM
Y. CURB P.[.
owT�ER The iamILyon Co.
co IMP No
MVM
ADDRESS
TRUNK PERMIT NO ROAD PERMIT NO.
AFFIDAVIT WAIVER EASEMENT RECORD. INSTR Np DATE
Cnr TEL. NO.
LEGAL
DESCRrPrIDN LOT NO
HWY OR ST. WIDENING
BLOCK TRACT 16 2 II
CRO4CHIMEAa
NO. OF BLDGS,O.
SIZE OF LOT NOW ON LOT-
(^'�
USE OF
GL
BUILDINGS
CHARGES
CONTRACTORIranP.Snm
TION CHARGE FEE
ADDRE _
MINT FEE
crcv TZOTCO TEL NO. Z
DISTRICT NO GROUP MAP D BY
X
STATE LFCf
LICENSE NO -� CLASS1
/w
NO DESC I ION WORK FEEPUUaUCE
SE R CONNECTING TO��
VALIDATION
SEPI AHK, SEFPAGF P1r ORPIT$AND/ORDRAHOUSESEWER
CONNERING TO
PRNA SYSTE
CONNECT ADDITIONAL BLDG OR
WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT, DRAINFIELD
ExTN., CESSPOOL, DRYWELL MANHOLE
At1FR, REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL WSTEM
OWNER'S Permit 11
10 50
I a b P
AUTHORIZATION I TOTAL FEE
7T....
I HAVE At THIS DATE A CONTRACT WITH THE 1R1EII4 NAMED CONTRACTOR TO
CONNECT THE ABOVE DESCRIBED EXRTING DWELLING TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_
OWNER OR ,
OWNERS AGENT
041
ADDRESS
Signature of Permilfee Date- 7 fBE REVERSE FOR EXPLANATORY LANGUAC4
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