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Home My WebLink About0897A (6) WORKER$'COMPENSATION DECLARATION I hereby offirm that i have a certifimte of consent to seif � 92mo2ovws�ai � insure,or a certificate of Workers'Compensation Insurance,or �6^a2o a cerlified topy ihereof($ec.3800,Lab C.} `�B°� APpUCATION FOR PERMiT . Policy No. Compony 0s C ❑Cer��f�ed copy is hareby furnishad. SEWGR - SEWAGE DISPOSAL �Cer�ified copy i�filed w�th the counry huilding inspection COUNTY OF l05 ANGELES BUILDING AND SAfETY departmeni. Date �3��T qpplicanr V� �e8t FOR AAPIlCANT TO F{LL IN 7 CONNECTION DATA CERilF{CATE OF fXEMPTION FROM WORKERS' �iip�� COMPENSATION INSURANCE nooxess sinirow � oevrH�, (This section need not be complered�tf�he work involved by the ��iitr Diamond Bar �N�aE aEFERENce � " � permit is for one hundred dollare(�lOp)or less.) � tow¢a KARE5F TYPE OF CONNECTION ^ I certify tha�in the performance of the work far which this �QpgSg_ IENGTHFRDM permit is issued,I sholl not employ any person in any manner Y� Cuae .t. M.L TORL � 7 so as to 6ecame subject to fhe Workers'Compensation Laws. owr�ea wffi pI1 CiO. [p.IMP.NO. JOB NO� � �� TRUNK PERMR NO. ROAD PERMIT NO. Date Applicant Aooa�ss � NOTICE i0 APPLICANT: If, ahe. maktng fhis Ger�ificate of nrrionwr WAIVER EASEMENT RECOR�.INSTR.NO. �ATE arr hi No. Ezemption, you should become subject to ibe -Workers' LEGAL Compensation.provisians at the ta6or code,yau man�4orthwith DESCRIPTION iot No. � Hwr.�si.wioeNin�c comply with such provisions or this permil shall be daemed revoked � e�ocr: TRACi STATEENCROACMMEN7 � IICENSED CONTRAC70R5 DECIARATION NO.OF&DGi PERMIT NO- SIZE W LOt NOW ON LOT I hereby affirm that I am licensed under provisions of Chaprer �� '� ,� (� 9(wmmerxing wi�h Sec�ion 7000)of�ivision 3 of the BuSi- gWtDINGS cnnac,�s � iress ond Profestion�Code,ond my license is in ful!force and �� eTfBcl. CONrRACOQ Y�A �-e.Str l�G S� �1(�'• CONNECr1aN CNARGE FEE Y CicenseNvmbe7�681A �IC.C�0p55�22p Appp� �t RE�MBURSEMENTFEE 6. COI1hOCf0f Pan Diest Daf2 PJ�p� fR�, DISiRICT NO. 6ROUP MqF PROCESSED BY � NOTCO re�.wo. �7 V �I am exempt vnder Sec. of the L.A.Co. �ArE ,�. 376g�4 c nss C4Z (/ —J BN � O LICENSE Z � � � Plumb�ng Code and/or Sec. of the ^b� DESCRIFT40N OF WORK �e FINA: U � 1 GUBLSC SEWER CONNECTING TO q nn DATE f�� VAL{DATION a B.8 P.Code fo�ihe folfawing reason � w ��, SEPIIC TANK.SFEPAGE Pli�R L f/7 � P�iS AW!ON�ftAtNFIEL➢ F�Np� 2 ' Date .. +NwSE gXEx CAtJNKr�NG to. _.. .. . er �� PRIVATE DISPOSAI$YSTEM � $1911QYVfE CONNECT AODIi10NAf OIOG.OR OWNER-BU7tDER DECLARATION� woaK ro F+aersesewea � OVEFFIQW SEEPAGE PIT.�NAINFIEI� I hereby offirm that I am erempi fram the Conhactor's ticense exrti.,c[ssroa,oRvweu,m.aNHae Low for the following reoson(SeC�on 7031.5,BUISnB55 00(�Pr0- PLTfR,REPAIR OB AeAN�pIV HpU$E � fessions Code}: se�R oe oisvos�t srsr�t � ❑I,os owner of the property,or my employees wiih wages as their sole compenmtion,wili do�he work ond the arcucture � is not intended or offered for sale(Section 7044,Business -�,�, � and Profiessions Code). OWNER�S Pe�m�t S �Q Q `��`' r Y ❑I,as ewner of rhe preperty,am exclusively contrnciing with AUTHORIZATION TOTAL FEE Q7 i:• � o + � Q licensed contracton ro canstruc�tha Pf0�2Ct�SECt1011�044, �HAVE AT tH15 DATE A CONlRAR WITH THE HEREIN h14ME�CONiRACTOR i0 - BUSIlIB55 O!t(I PfOf85SiOf14 COCJC�. CONNECT THE a9pyE DESCRIBED EXISTING OWEtuNG i0 TNE oU81K SFWER � • `��7.5 r�' � CONSLRUCTION LENDING AGENCY • I hereby affirm 1ha/there is a construction lending agency SIGNEOTHIS DAYOF 19._ � • a •�i�S(��; ' for fhe perFormonce of rhe work for which +his permit is ��A� OWNERS AGEM i ss U e d(S B C.3 Q 4 7,C i v.C.). � �.().�.,—Z)I � Lender's Name nooaess lender's Addresa 3 I certify thal 1 Fwve read this applicotiort and state thal ihe ubove informalion is mrrect.1 ogree to compiy with ol�County ordinances and State laws regulating Plumbing and Sewers, ond hereby aulhorize representatives of ihis County to enter upca�heabnve-jmerslion .property��forinsKsedionpurposes. �1� -�i-3/�-�;� � , Signa o'�Permittee ote SEE PEVERSE FON E%PIANATORY LANGUAGE � � �m d d d Q m W �« � � , �Gl K m�� m �i M � � �~� �� d�� U �� py �� .. . �.. d O y ;.��«Cw O � � �` � 'i: N �„� o�i 0�'?1�0`* Q q^ �•�•,� ° "^p`^ $ ° ° ° ai F� o � a a� p� m m � � � p � w�'e:� C�.7:�.°4 Q,O � �"' 1: A`J R �;'„ ? . . � � t�"i +.�'', �•� � .�ei�� m F � � e„'U � �•�."�'' C m 'Y � .«�'C.e...4 ��.7.a � oki ��' ta7"�CJ "` o�l�-e .�,�-.-' ., .. ,_.,�rJ � ^�. � � q �i,.�„Q•tl yq ��„ro•yy,lw � w y�,..�� :e d�� _ . a � o � dR M�.+, v '4dh". w �n Q'i � � 'n p� C 1. p� O tl �w.� Q.^Q �a C . 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