HomeMy WebLinkAboutNo Permit NumberWORKERS' COMPENSATION DECLARATION
1 hereby affirm that 1 have a certificate of consent to self
insure, or a certificate of Workers' Compensation Inwronce, or
a certified copy thereof (Sec. 3800, Lob C.)
Policy No. Compony
❑� Certified copy is hereby furnished.
7Y� Certified copy is filed with the county building inspection
department.
Date 4/4/86 Applicant Van 71i ant k Rein
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, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor code, you must_forfhwith
Tply with such provisions or this permit shall be deemed
t ,ked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter
4 (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 -47681 4 Lic. Class (,',-.1� 2
Contractor Van Diest Date /86
❑ 1 am exempt under Sec. of the L.A. Co.
Plumbing Codeand/or Sec. of the
B. 8 P. Code for the following reason
Dote
OWNER -BUILDER DECLARATION
I hereby affirm that i am exempt from the Contractor's License
Law for the following reason (Secton 7031.5, Buisness and Pro-
fessions Code):
❑ I, as owner of the property, or my employees with wages as
4 their sole compensation, will do the work and the structure
is not intended or 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
1 hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued (Sec. 3047, Civ. C.).
Lender's Name
76M42D
Ciao mtv L,831 APPLICATION FOR PERMIT
SEWER - SEWAGE DISPOSAL
-m 4/ v&OUNTY OF LAS ANGELES35 BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
CONNECTION DATA
FILL
BUILDING
ADDRESS 21050 E. c3.T-L Rim Dr.
STATION DEPTH
LOCALITY Diamond Bar
MANHOLE REFERENCE VFTER
NEAREST
CROSS ST'
TYPE OF CONNECTION LENGTH FROM
Y. CURB P.. O P.L.
OWNERCo.aonCO.
P.C. NO
IMP, NO.
MAIL
ADDRESS
PERMIT NO. ROAD PERMIT NO.
-R. NO. DATE
CttY TEL. tJO.LEGAL
DESCRIPTION TOT No. 35
JT'RNK
Y. OR ST. WDENNIG
II
BLOCK TRCT 43162
F E Nt
NO. OF BLDG5.
MIT
512E OF LOT NOW ON LOT
USE
Res.Qv-
`
aARGEs
y
CONTRACTOR u`i Dies4 & Son
CONNECTION CHARGE FEE
A 1494 Hamner Ave. T A
REIMBURSEMENT FEE
Norco 734-7442
DISTRICT NO. GROUP MAP -3 DBY
Car TEL. NO.
STATE LIC,
LICENSE NO. 681 L C1A55 2
BK
NO. DESCRIPTION OF WORK FEE
v
HOUSE SEWER wNFXrnNG ro
PUBLIC SEWER
HNAL
VALIDATION
°"��'3
SEPTA SEEPAGE PIT OR
AND/OR
PITS AND/OR GRAINFIELD
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTE
FINAL
BY
CONNECT BLDGOR
WORN TO HOUSE SEWER
HOUSE SEW
OVERFLOW SEEPAGE PIT, GRAINFIELD
ExTN., CESSPOOL DRYWELL MANHOLE
ALTER, REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
4f-,. ,. _...
OWNER -S I Permit s
®• • • i 0
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THF HEREIN NAMED Cr-TRAr'IM
I „ ` 7 5
CONNECT THE ABOVE DESORIBED EXISTING DWELLING TO THE PUBLIC SEWER. • _
SIGNED THIS DAYOF 19_ F _ t7. h
OWNER OR
OWNERS AGENT
ADDRESS
Lender's Address
I certify that I 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
upo a above -mentions property for inspection purposes.
41-7
Signature of Permyllee Dote $EE REVERSE FOR EXPLANATORY LANGUAGE
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