HomeMy WebLinkAboutNo Permit Number � WORKERS'COMPENSATION DECLARATION
1 hereby affirm that 1 have a certificate of conseN �o self vz-000s orw aie� �
insure,or a<ertificate of Workers'Compensation Insurance,or T��
a cenified copy�hereof(Sec.3800,Lob C.) `E� APPLICATION F�R PERMiT
� Policy No. � Compuoy- �s
' ❑Certified copy is here6y furnished. SEWER - SEWAGE DISPOSAL
�Certified copy�s filed wilh ihe county building inspection COUNTY OF LOS ANGELES . BUILDING AND$APETY
da ime 1.
bar� �31,$7 APP���a,,, Yar� Diest & San� ZnC. ppA APPLICANT TO FILL IN 7 f{ CONNECTION DATA
_
CER7IFI COMPENSAiION�INSUR NCE RKERS' nooREss ZO Fast Bjm Ln• srat�oN �(, o��r�/p/
' (ihis saclion need not be mmpleted if the work involved by tha nunr�ae eeFcaeNce � °
�«,�,TM Diamond Bar ,,�q
permit is for one hundred dollars($100)or less.j �AREST TYPE OFCONNECfION �w�rN rapen ? 5'
I certify that in the performance of the work for which this ckosssr. � r. cuae e.i M.�.roa.t. J"
permit is issued,I shoif not employ any person in any manner .,�,,,T'�
so os to become subject ro fhe Workers'Compenwtion�aws. pK,�p n.u+i�� c0.inna.No. ioe No. �d
��� TRIINN PERMIi NO. ROAD PERMIT NO.
Date Applimnt aook[ss �
qfFIDAVIT `/✓/+��R EASEMENT RECOft�.INSTR.NO. PAiE
NOTICE TO APPLICANT: If,.after making this Cer�ificate of �iTY TEL NO.
Exemption, you should become subjecr to rhe Workers' iE��
Compertsotion provisions of the La6or tode,you must fonhwith DESfRIPTtON ioira. 1 Q Hwv.oa sr,wioeNiN�
camply with such prorisions or this permit sholl be deemed .�A A 1r
revoked. siocc TRAC7 y+�82�} IY STAiEENCR0.4CNMENT
LICENSED CONTRACTQRS DECLARATION rao.oF a�ocs. °ERM�T�'�O�
S2E 01 t0T NOW ON l0T `_, ' � ��J�
I here6y affirm thal l am licensed under provisions af Chapter ��� �:f '7
9(commencing with Secaion 7000j of�ivision 3 of the Bu4i- BUIIDINGS Res. cMnaces
ness and Professions Code,and my license is in fu41 force and �
effect. w�urzncrors coN�a�or�anuc,�fE[
Licensa Num6er 3768�4 Lic,Closs G 42 • � aEiMeuesemervr ffe a
�o�u 7 Hamner Ave. 7zA �/�Ae� o
COfVt�a[iaf V3t1 ��t. �nte��t�IS�_ [ITY ���Q 7EL.NO. I!��1"F`TG DISTRICT NO. GROUP MAG PRp�[5$ED BV V
' S1ATE UC �j 8K PG Z
❑I om exempt under Sec. of the LA.Co- ii��Np. apss v �3 1j �
No- DESCRIPTiON OF wORK FEE � ~
Piumbirg Code and/or Sec. of ihe sani V
HDUSE SEWER CONNEGTING i0 �7 � onrc �Q�7 VALIDATION W
B.8 P.Code for the following reason �&�«�p � V � a
. SEGT�C TANK.$EEPAGE Pli OR N
PiTS AN�/pR ORAINFIEL� ��NA� `� ?
DO�B lq�SE 5Ey/EH(pNNEC7ING TO BY
PRIVATE OISPOSAI SYSTEM ,,.
$ignature CONNECT AOOITIONAL BLDG.OR �
OWNER-BUILDER DECLARATION WORK 70 HOUSE SEWE4
. QYERFL�W SFfPqGE PIT,DRAINFIEID
I hereby affirm thot I am ezempt from the Contractor's License � exrni.,[essvooi,oevw[u,�unNNo� _�_
Law for ihe following reason(SECfO��O3I.S,BUt911E14 011d PfD- ALTER,BEPAIN OR AOANWN HIXISE
f25510115 COdB�' SEWER OR DI$pp$AL SVSTEM
❑1,a5 owner of the property,or my employees wiih woges os ��i��!N
� their sole compensotion,wit)do the work and the structure ,.
is not intended or offered for sale(Saction 7044,Business fr• • • • } Q
ond Professions Code). OWNER'S Permit E �� 5�
❑I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE � ' '��'��
IfCE[15Cd COf11�OCfOfS�O ConSfIUC1 Ille PlD�CC1(SBC�iOn 7OdG, I HAVE AT iH15�ATE A CONTRACT WITH SHE HEREIN NAMED CONTRAC�OR i0 �� :,r=
BuSIf1ESS Of1C��OfE55tOn5�ot�e�. CONNECT THE ABOYE DESCRIBEO Ex15iING�wELtING iD iHE VI/BIIC SEYfER, �1�'�'���-
CONSTRUCTION LEN�ING AGENCY � '�Q�_�?
I hereby affirm 1ha1 ihere is a construction lending agency StGNEDTMIS DAYOF I9_
for the performonca of the work for whlch this permii is pW���Nf
issoed(Sec.3097,Civ.C.). � -
nooa�ss
Lender's Name
Lender's Address
1 certify that I have read this application ond state�hat the
above information is cwrect.I ngree to comply with all County
ordinances and Sfate laws regulating Plumbing and$ewers,
and here6y authorize representatives of�his County lo enrer � �
upan ie above- ntionad property fo�inspenion p�rposes.
$ignotuf0 f PCrmiHee D �� SEE FEVEILSF iOR EXPIANATONY LANGUAGE
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