HomeMy WebLinkAbout8474AWORKERS'COMPENSATION DECLARATION
Ihereby affirm that I have a certificate of consent to self
insure,or'a certificate of Workers'Compensation Insurance,or
a;ertified top thereof(Sec.3800,Lab C.) CE BDe IRE.B/ell
Policy No.jjO i6_company* eft Amerman. APPLICATION. FOR PERMIT: . ....:::.:... ::.. s
E3 Certified copy is hereby furnished.SEWER - SEWAGE DISPOSAL
Certified copy is filed with the county building inspection_. COUNTY OF LOS ANGELES BUILDING AND"SAFETY,.,,
department.
Dot. Apphcam LeAverton FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDRESS 1016 Summit 'd e Drive STATION DEPTH
This section need not be completed if the work involved by the UPPERMANHOLEREFERENCEpermitisforonehundreddollars($100)or less.) LOCALITY Diamond Bar LOWER
A certify that in the performance of the work for which this'CRoss 5T TYPE OF CONNECTION LENGTH FROM
Y- CURB P'. M.L.TO P.L.permit is issued,I shall not employ any person in any.manner
r
permit
as to become subject to the Workers'Compensation Laws. OWNER MJ Brock & Sons, Inc.CO.IMP.NO. JOB No. 0 r
ADDRESS P.O. Box TRUNK PERMIT NO ROAD PERMIT NO-Date Applicant 1 350
VTICE TO APPLICANT: If, after making this Certificate of CITY Brea 2622 TEL.NO. 2 —8p1 J
AFFIDAVIT WAIVER EASEMENT RECORD,NSTR,NO. DATE
77Oemption, you should become subject to the Workers'.,
compensation provisions of the Labor code,you must forthwith. - "k DESCRIPTION LOT NO.4 HWY.OR ST.WIDENINGcomplywithsuchprovisionsorthispermitshallbedeemed
revoked. - g BLOCK TRACT 42571 STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATIONNO OF BIDGS..PERMIT NO.
I hereby affirm that I am licensed under provisions of Chapter-- -
SIZE OF LOT NOW ONUSEOF9(commencing with Section 7000)of Division 3 of the Busi-BUIIDIN residential
nd
CHARGESessandProfessionsCode,and my license is in full force aneffect. CONTRACTOR Leaverton Bros., Inc. CONNECTION CHARGE FEE
ilicense Number 11 1964) Lio.Class_036 ADDRESS P.O• BOY- 17118 REIMBURSEMENT FEE
Contracioi,Leayet'ton Date 3/20/87
cnv Irvine 92713 TFI.NO 863-1180 DISTRICT NO. GROUP MAP PROCESSED BY u'
1 am exempt under Sec.of the L.A.Co. .. ..', STAL
ETE
NO 191969 LIC 036
BK pG
NO DESCRIPTION OF WORK FEE
FINAL OPlumbingCodaand/or Sat. of the
Q f/ yALiD ION UJHOUSESEWERCONNECTINGTODATE (!/
PUBLIC SEWERipB.8 P.Code for the following reason
SEPTIC TANK,SEEPAGE PIT OR1:' y}. PITS AND/OR DRMNFIELD FINAL ^Z
Dote
7 HOUSE SEWER CONNECTING TO BY Com+PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
R OVERFLOW SEEPAGE PIT,DRAINFIELDi;I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE
for the following reason(Secton 7031.5,Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSEdoneCode):S£WER OR DISPOSAL SYSTEM p"
7l
p4 ILA
0 I,as owner of the property,or my employees with wages as `t
J
their sole compensation,will do the work and the structure
is not intended or offered for sole(Section 7044,Business
and Professions Code). OWNER'S Permit o"27.5 g;I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE 6217, S? m o q x +.
L licensed contractors to construct the project(Section 7044, - I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
Lr r'J G L'
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.n c L 0 aCONSTRUCTIONLENDINGAGENCYWJ1O
j l hereby affirm that there is a construction lending agency SIGNED THIS AY .
for the performance of the work for which this permit is'
oOWNE
wnsDRissued(Sec.3097,Civ.C.).
Lender's Name
ADDRESS
i
Lender's Address
p^a.I certify that I have read this application and state that the
A above Information is correct.I agree to comply with all County
M ordinances and State laws regulating Plumbing and Sewers,
sy and hereby authorize representatives of his County to enter.
A
he above-mention property for inspection purposes.
64 23 J07 ,
Signal ur of Permittee Dote SEE REVERSE FOR EXPLANATORY LANGUAGE
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