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HomeMy WebLinkAbout1478A __.___._....,�_..___�___ .. ..:_.____�.._:—,_.�.. ...--,�- _:__:: �,._,_..�_.:_.m.__..::�.._..._M.�.�,_.�..,..�.�_.:.._..,._.___a_..:__ .. _.. :.,:. - --� - :., _. ,; ,:.. . WORKERS'COMPENSAiION�DECLA�RATION �- �� � � ��� � � `�� � � ' �` ' "������� � '��` �' � '� � � � � �� �- " � ..� .. .. .. . . . . . . .�.,.:�... ._. . . :.. . .. .- � .. . . . . , ...�:.. : . . .. .:�.. . . . , I hereby affirm that I have o certificate of consenj to self . nsure,or o certificate of Workers'Compensation Insuronce,or � �acaazo . ,� � a cAYtifie � of{Sec.�3800 � C.) ce uoe(eev.aiei.� ' . . . . .. . , . . - ._.:., ...,�......�,...,_.._...._. _ ._. . Pa��Y No-�'�7����}Company ��• Fund �, APPLICAtI(►�A,N/�.�+��Rr �'E�+R1�16���- �. ❑Certifj[�,Kereby fumished. SEWER ' S�iV�'1�9E DIS��J�L � ..,,.. ... , ._..... ... ...._..._. .__.... . .�.._. .... ... ... .. ..._. .... .a .� ..�..:. . ..,..�...,. � ,., � . . . .,,, , .�..,.�.... ,:. �:-�. .. . refied mpy is filed wiih the county bwiding inspect�on - COU�NTY OF`1.05%�iNtb�1.E�' BUI�DIN�'s A�D SAFETY ' :. :::.�:. dePartment. . . . .. .. . .. . ...... . . ....... ........:.,,, ,.._..,.,_�... ': Dore p� F1'EETf12.21 FOR APPUCANT FO FILL IN� CONNECTION DATA� �� - � s7S,2APPi ca 7 �� , CERTIFIf��TE`OF'�k'E]u�fpl'I'Ot�f`�RFTM"4GOI�KERS BUILpING 3 - � ION oEPTH " '' �' [Oh1P€KTSA`TfbN'1F75URAF7t� aooaess R' ' -�(TF�is set(ion need�nol�6e comp�eted if�tke work involved tiy the��� " � uraea �. permi(-is for one�hundred dollars(5100)�or less.) ���'4L1TY �n+'NNO�EREFEREN� �owea ��'� I-certif� thai�in the ��erformance�of the � " '� � veaaesi , � rvPeoFcoNNecnoN "�� '�-' ""�N�iHF2oM-'" '��� � � y � p work�for which this ceosssr. ermii is issued,I shall not em lo an Y� CURB a.i. M.�.To P.�. p . p y y person n ony manner �.c No '9 C� �� So as�q 6ecome subject to the Wo kers'Coriipensation Laws. owNER � E CO.IMP No. ioe Nd. " �'Z5 ... �. ���.�• ;�'.. .,�,', •,�� ..�•;.. :'�:'� A�DRE55 PO �011. �s!`-J iRVNKoERMITNO. � ROA6PERMITNO...-.... ._,...._._. Date Appi cani � � � ' ' � �� NOTICE�TO APpLICAfJT: If, ofter makin���this �2ftI��C41E o€ ����-�-��� • g1g�g67_954� AFFIDAVIT 'NAIVER E45EMENi RECORO.INSTR-NO. �ATE e �;T� Covina TE�.No .§�mplion, you .shou(d become su�b'jed to ihe Workers LEGAt - f perisation piovisions of ihe Labor code,you must forihwith oesce�vrioiv iorNo nwr.oa sr.wioeNw� ,,.npiy with sucn provisions or ihis,permit shall be deemed 35754 �' eVoked BIOCK iRACT SiATE ENCROACHMENT ' ' ' ' ' ' '�LfC�NSE,D'CONTkACY�6f�S D`�CL%1(2`d;T'IO'K7'` �`��� �� " No.oF e�o�s � � PERMIT NO. ' SiZE OF LOT NOW ON tOT � I hereby��aff m tha�I am licensed`under prowsions of Chapter useoF : 9_(commancing with Section�7000)of Division 3 of ihe Busi- auimwes S1Y1 • R@S• cHnec,es . ',."ne53"'6nd Professions.Code,and my license is in full force and �T �ry/{� ..�' ¢{teCt.-..,. , . . . CONTR4CiOR ��j��� CO3YSIJ.• :.ONNECTIONCHARGEFEE } Lcenset:lu 62f 474887�<<.c�asg`�� b34- AOpRE55 �GG eechwood �r RE:MBURSEMENTFEE o . .� �O�haC10Y Freema�n ��`- ' pafe �S/20/86 ❑ISiRICTNO. GROUP MAP PROCESSE�BV V .. .. . . . .., . CITY -� TEi NO. � BK PG Z �. ❑I am exempt under$ec � �of the L.A.Co. � uCENFSE No. ry�7 887 Cin55 �,�j4 � � ; Plumbin Code and�or Set.�� 01 fhe h�� DESLRIPTION OF WORK FEE ' V �� � 9 - ' - HOUSE SEWER CONNECTING TO � '1� Q/1 DA E� � l2Ly VI�LIDATION 6. , B 8 P.Code for ihe following reason� � �" ' � PuauC sewek � .d v ✓ Y'Fv , y ' ' .� SEPTIC TANK,SEEPAGE PIT OR � DO}2 " PITS AN6/OR DRAINFfEID � � BY A� � HOl15E SEWER CONNECTING TO ' � � � � �' ' ' PRIVAiE D'ISPOSAI SVSTEI� . $IJr1OtU e � . CONNECT AO�ITIONA[BI.6�G.'OR� "" - " ► � '�� OWfJER6U1LbER'�D�ECLA12AT1L5N ' ��"�" ��� '� woRKroHouseseweu -� " .�� I here6y�aff rm thai I�om e empt from ihe'�Coniractor s-Cicense�� ���" �x7ivF��55vooiGokvJ.wEUA�nv�iiote ' � - � Law for fhe following reason(Secton 7031.5,Buisness and Pro-. n:reR,REapip oR netWooN HouSE �. r�"ion5 CoCIeJ: SEwER OR DISPOSAL SYSTEM � ' "' '"' � �."�`ti r, ri - .I,os owner of ihe property,ar�my employees wirh wages as � their sole eompensation,will do the work and the structure r, ° '� ^ � � � ; is�nof intended or oftered for sale(Sectipn 70d4,Business �� � � � � "and�Pro4'essions Code). OWNER�� PermiT g io 50 ! o <+:'j'.;�(,'� ...... _............... �� ❑I,as owner of the property,am exc!usively contracting with AUTHORIZATION TOT/�1L FEE 2 0 .: � ���.5;,'�� .� licensed�coMractors ro consiruct ihe project(Section 7044, ;Have ar rH�s�nie a coNiRAQ'W�M rHE'HERFIN N6FnEb C6MRACTOR Yo' � BUSinESs qnd Profe55lon5 CO�'@� CONNE"T THE ABOYE DESCRIBED EXISTING D\VELLING TO THE PUBIiC$EWER'. '�" �!.V.�:��C . ._� . ....y....�.... � p(/� � . "- -- CONSTRUCTION�LENDWG AGENCY �""'�""� -� � � I hereby aff rm ihot fhere is a consfruction lend ng agenty S:GNED THIS DAY OF 7�7" for the performance of ihe work for hich this permH s ov''NEROR ��� OWNERS AGEIVT � . , issued($ec 3097,Civ.C.). - Lender's Nome � � � � �-� �� � �'DRE55 ♦.}- . . : . � . . - .,,,. ,..�-. .::;., -. .... .,,�_- Lender's Address . . .. ..� ._ . . ...: -...��= ..,-.... ._....�..-,-_� �,._...._, __ �...... . ... .., .. ._. . .....___ ... ...... .... ....._. . .-... ,...__...._...... ..,........ ... .. . , . I certify ihot I have read this applimtion and state that ihe obove information is correct.I ogree to comply with all County ' dre{inances�dnd$tare laws regulating Plumbing ond Sewers, and�hereby authorize representatives of ihis County�o enier � � upan the obove-mentioned property for inspection purposes. ,,.. `�("�',,'���.c.c�w.m�-- ��c-�=�L . � Signatureof�Par 'tiee �ai� SEEREVERSEFOREXPLANATORV�LANGUAGE��� � � � � - � ' � � � � " � .:.... , ,... ,M_�. .,�:;,�:.. �..�.�:: u,. � . ., c::':-< r,;,;:g. . . �., .._ ..� . ..r..���{ - � . .. . . ... _. :'.:, a..-...., "-�J '�", '�- ,.*,'e ..ii:,..�.:. »:;,. �.:.t . .. ... _. - .�. . .. .. . .,_.__ ..�� _ _ _ _ _ -- .._...� �,--,.. . . _ . eNsw�cvort�s aios�s _. -._...._ _.. ......._.0 . �_...._..�.�...W_. _ .,.... 4"' �, , �;: ���i: . , .; ., :' } �� ; _:?Y?V�R-�UIL�EA�D�CI.AYB.a�'fi'IC)1\T . _ . . ,._.._�,:. . ,g,}+��Oyp�,� DATE �INSPECTGR'S SIG�IATURE F.��.A P �,p, ,_,___ I IICfED�A'.1��13'rR.'�t�'idt�8ffi CA2IIi�f fCOYH L}t2 CAIlYt$LQOP�A NEW NOUSE SEWER � License Law Por's�2 f�llowiag reaaon(Szet6on 7�31"•]�� �'�` Bra�ixess a,xd'Pro,j'sssdasu �odrs/: Aay city ar couuxy CONNECSADDITIDNAL f � T� . - .. . . .. . '1'eQn � ' �' BUILDING OR WORK Tf1I.f5CI3 LY¢s[s L'9'I16sR:�1 f:OASL'iYLCE�S�E6.w':8 i'OtJB� ' .,..,. --� _ demoYisb,�r rs�ar.an�r a�rucemre,Prfas�Se sts isaeaanea. ' SEVTICTANK,SEE�,PITISS� � . .• .. . • .. ._ •, �--� AND/OR�RAINFIELD � , O180 - Qtbs9'�S �be appidca»a�vr b �,�I6�3s' Bsf�5j¢fE , --- .- .... � . . s@gtted state�ee�,a 3�irat�ia ss a#eensed purauemt so t8a - cssaoo�O oQvwei�C � . � � .. - - �•• . ..-._... ,�._.".- . . . .. . prnatiaioxs a¢tbe Cora2rueesr'r P.eces�ee Law(�:fxrpter 9 �- ni�k,aeaniR,sEwea oa . � . .. ._ .� .... � . � _.�, ._.� (crosoueeenmeg.ai8d Sethion?O�GUI of.�dviss£mn 3 oj:dye <-� SE\NAGiDI5PO5Al3V5TEM 3 . ..." „ . . -.-.. '. , � .__.__....f._ ,—. � � - Eusinesc a;u8 I°rofesseo9z± Coda)m��+at'mz is azesnpa .: DISCONi4ECT PWG NND ! -. �. �hxv�efraias�a�e basi,a f�r•CTre slte�ed¢xe»saEioss.Aug. �;.. ABANDON HOUSE SEWER , . . . ._....__.., . _..,.... ,_...... �ir6oTallon nJ.Ser&sosz 7dJ31.5 b rm 1is�zcx ara � ;, enc�Fiu sevric rawcs r,�' ' . .., Y Y��' f $�rma.t ;�e� SEEP,PR�SJ CI eEssroo�s❑ .,,-,.. .---,.—z,,,-5--„ .-., � - ...._ . swbiest�a��,�p�lscn ,. �c".a.roP pa�aaFty o�xas»:om�baas � .,.,-�-._.. _ ,;, . .,.�_. .. .' .-- ..��.:y,,,. �.e,..,, e.�, , ,,�, ,_. .. . f��iu�d'red dotluvs{�350Gp: . .. - _ � ,.. � A I,as the�wner of th�Bray�ex�q wiSC do she mm�.a•rd � _.. . . .,, . . ., _. . . __. . . . .. .. ... . _.__ , ' ` , y- ;.. i_r: -. .., 2be suu$is not inxes�ded ar oQYexed#ar sete• , - y '.� ... ...... . ... ... . . . ... ...�..: . .... , � dgec. r044, asiasas.�rul Prafzsxeoa.c-Code:�'l��'.^on- � y � .,..... . . . :-� --.� ;..,. .... �,.,°;.....SracEor'r Zieesesa Lcw.s�oas srzre�a�rp%y to�vc a r og . ...... .. .......:_ . . ._ .. _ _ __ . _. _, �:',':+.; pro�erey,ohn buiAda°c.sra¢moes ekerean,.an�wkro�:oes � . . ;. � . ..�.,� ... . . .. . . . .......: ..:.� -. . . .:,� . . . iucb euork &�rnself�ravddec8 sbat s�acb dmbroveenants ... .. . .. . . . . .. .. � .. . . . . � ar�soo>9vi8eAded'ar c�f�red';or sade.%�$o,warier,abe �. �.. � . : . �� �. .. . .., . :..:;,.. ,.. ...-. . „ .� ,. ." , :....;-.. 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