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HomeMy WebLinkAbout1484A �__ .... . _ _. � , _ _ .. . .,w ,.�. m :n..� ..�.,..._ M� ..... .. ,......,... .._�.�. .�. �... .....�,._�_�.....M.W�. ,�_.......�_ .N�....�__y._�..�.�.-�---�__. i WORKERS'COMPENSAtibR"6fCCICRQ1�Tb�lJ�"�'��, . � - I he�eby affirm that I have a cerhficate of consenl to seif insure;or a�certificate of Workers'Compen1sation Insurance,or �enen2o ,,, o cert�fiea���(Sec.3600�L�b C 1�+.uC�. .. �seoe leEv.eien .. . . . .�.w s�� �� ��r��s � � �►PPLrCA"�'I�?I�'��i��'�RMI� : �rt_ Volicy N .�7/ Company • �� -�� � � � � �SEWER- SEVI/AGE �ISpOSI�I - ' �� �.�� ❑,Certif6C�Y � hereby furn�shed. . - , . . ,�. . . .. . . .. ,., . . . ..�, . . .. .. �p-� COUN7Y OF L'05 IKNGE�ES�� � BUlLDING AND SAFETY � .Cf.;Certified copy is filed with ihe mun�y building inspeUion . ,._:r,.... . .,, .,�... -,. �..,_ ....,. .. . .. _ .__ .. _ . _. .r.-.. .p::a.;�-m� .s. � r'.:�:de�ff��`%86 Freeman � ... . . . _._.... .. ...�....� � Dore Applicant FOR APPCICANT7G�FII.L 1�1��'' �" � CONNECTIOPf D111'���"���"�� __ . _. :,;;.;;._+ ..�. �, - - � CERTIPICA7E O��Ef�f�0�`FROM WOR'�S �� � . ..�,�. .. .-rxw... . . ..... ........ BUIIDING . . . - . :. 'COMPENSA7fON��f�T$U�2Y+1�'�E .4'�DRE55 STATION DEFiH . . . . .. . ... ...... .. . . _...._. .. (This section need not 6e compleied if Ihe work involved by rhe ��� B� r�a.Nr+ote a�eaewce � ��- � ��"��� " � ' "�Pvea � pArmi�is for one hundred dollarg($100)or less.) �ccnlrcv . iowea ����I certify �hot-in ifie performance of the work for which rhis cRosssl. } rrvea[oN�'*i0u terv�rHpRo,v� . .�' � Y. CJRB P.. ...., M.L.TO G.L .��� permit is ssued,I shoil not employ pny person in any manner - '""`" � -sa ds to become subject to ihe Workers',Compensation Law�s. ., AI3DE�7�GRp� � `�"°- d p yfi� �..,. .. . .. .�.... .: „ ..\NNEr2 . . . . ,.... .. .�....._ ...... CO IMP.NO JOB M1D... . . . . :-� ': -.". ' . -. :�. ^�...,. �.'.. '.': . . .. . .. .. . . . . . ... .,. , . , . ....,,... � ' �. ' � ��� ' TRUNK PERMIT NO. ROAO PERMii Np � Da�e Appl can+ m 000aess .. .�... _ _ , .. . �' � .� ' .. .,xr.�+..a�»�rrw .e�.w-^-� '^'•�"""'�'"^""' qFFIDAVIT WAIVER EASEMENT RECORD.IM1ISiR.NO DAR� e.. �. NOTICE'�T'O �1T'PY��F.�VT I�q�ter moking this Certificate of arv Covina TEL NO. ,��H 6 •• � .�,�mption yo� should 6ecome su6jecr ro the Workers' iE�Ai � npensation provisions of the lobor code,you must forihwlth oescairrion, �oruo, - -- �-�` - ���' "�' '�� � '� � .nply wirh sucn provisions ar this permit shall be deemed � �"' � � - Hwv.oasT.wioeNiN�"-�' ���" - - 35754 _ - .�`revoked. ..�... - . . ,. .. . B:oCK rRACi . ...., ..,..., ,..,.,..,� SfaiE ENCROACH7vYENi.'. . . . ,.. .. ._. ... -,.:. '.':�.'.� ea�. .:... � �,,...,;..,:'.;:. . . . _ . ' PERMITNO. ����' � UCENSE�COI�TTkACT0�5 D`�CLAkA`('IOrI'� . No.aF eio�s � - -���--- -� ,. .'. ., ., iIZEOF�OT NCWONLOT ,', � ., .,'� �I hereby affirm that 1 am Iicansed under prov.isions of Chapter �SEof s121 � R�S� � �����"„��, .�� 9-(commencing wirh Seciion 7000)of Division 3 of rhe BVsi- BULLowGs � ._..._ . ..- . , . . �. .- , �. cHnaGEs. ,.„__,.. „_ ,. � , , ' .��n�ess'"6nd Professions Code,and my license is in f�ll force and � . . . . . " - CONNECTiON CHAftGE FEE� �, e{feCt. �t.7,f. . .... ..........�, . ;..,. ..... .,. CONTRACTOR ... .__....... ... -.. � L cense Num6er `�'t`�'8�7 L c C�OSS ��� � �� ADDRES$ REIMBURSEMENT FEE � . . o . :. . .. � ,��n...e, . . ..... ..:... . �., . . .:. . .< � .,_ e�/�. . . . . .. , ,.,........:. . . � � COnhOCfof Freeman �a12 8���86 DISTRICi h0 GROUP MAP PROCESSED�E�"��� . . .. . . . . C:Tv iEL.NG. . e � _._ � .�. . ..,.. . . .. . . . STAiE ,t �l LI j� BK iG o ❑I am exempf under Szc .� of the L.A.Ca ., uceaSE No. y�� gS 7 aaSS d � � PlumbngCodeand/or5ec, ofihe ,,, DESCRIPTIONOFWORK - . FEE . FINAi , . � No �'� - � � ,:' �- . . ��.;-., HOUSE SEWER iONl,dc`CTlfJG TO OAiE ��p 8.�8�P Coile fior ihe follOwing reason� � �e.,CSEwea ]�`� Q� �!J ;y/�/r+ VALIDATION . . N S.P�IC iANK,SfEPAGE PITOR FINAI � ,- ' ��. .,..:. ...� ..Y•'-�• :' .:.'"��� �PiTS ANp/OR ORAINFIELD Date HOJS:SEWER COM1NEi'ING 70� � � BY - . . . . . � .. ' . .. , .. ... PRIVAYE DISPOS�L SVSiEM �' . ,.. , . �. .. ,..��.: �;; � $(JnafUl@ - ,.++•..+� CONNECT AODITIpNA�BLDL.OR,' , � � �"""' ' ' �` N0�2Ki0iCU5%SEWFR . . � �� OV✓NER-BUILDER`DECLA12R`TI�Nw OVEFF;OvV SEE�4GE PIT,DRAINFIEID I hereby affiim that f am ezempt from the�oniractor's L ce se ez-r�,cFssnoa,oavweu,nr.aNHo�e ; Low�for the following reoson(Secton 7031.5,�Buisness and Pro- n.ren,a�va�z oe a3allo�h House � ;,:oa.sions Code): sewea ca oisPosni srsrenn ::;.j f,,.�'C!.,G i,os owner of the propeny,or my employees with wages as . . ..._..... z,.- ;�, ^ their sole compensation,will do the work and the structure ¢` � � � � �' is�not intended or offered for sale(Section 7044,Business ����-�-�� � � � � � �;�,�i�cJ' � � � and Pcofessions Code). OWNER'S Permif 8 ]_0 Q � _ �I,as ewner of the praperty,om ezclusively contracting with AUTHORIZAtION TOTAL FEE �� ��� :.� �,_'(.;"U � � . licensed mMractors to consirocr the projeci(Section 7044, � � �Hqve a*rH�s onie A coNrRqcr"w�-H'rHE�uERF;N NA.Mea cw.�ruacJo To (� � Business and Profess ons CodC). � CO��NER TYE ABdVE DESCRIBEO'E%ISTiNG d�VEf11NG10 TI?F�dU6L1�"'y`F`A/ER.� �,S5���,U b �. .�CONSTRUC7fOIV�L�ENL511"J'C`a��b.',�'�NfC�(�•`.�•,�•,'��.••:•�:.•,+��•��,•.• . � I hereby affirm fhai fhere is a construcfion lending agenty SIGNE�THIS � PYOF � .19� for ihe performonce of the work for which �his permit is OWNEROR � issued(Sec.3097,Civ.-C.). '� � own�easnp��ey�.�—�,�'�1 'V�-' -�--- � . . . . . . . . . . . .. �eoaess 1E.�'TLt"'��-� (d� �� YCJx N'i ti" - Lender's Name �.,,�,,, ._._.. _ .._......, : , .... . .- ,� � .. ., ... ;,,. . ,.-, .. ._,.::,�:c �...,_...._,__ ...._._,._:.. ... ,..._.... . _ •_ .,,... .._.__ .... ....._.... , . ....�_.. . .. Lender's Address w+:-.�..,w.w�w�.�..+�^o'^".�"w`^"",s"°"""'�o�.""ww`"""'w"'.".mm`-�.•+'w,..�.w++�.».�«,.w.�«e«. � -I cer�ify thot�I have read this oppli<otion and stale~thot ihe� . above information is<orrecL I ayree to comply with all County 6rclinantes and 51ate Iaws reguldting Plumhing pnd Sewers, and here6y authorize�representatives of this County ro enrer , . . . - ` vpon rhe above-mentioned property for inspection purposes. � � � � � �iYJv/�-�✓ ��"�� . . . . . ... . .... .:.... . .........,. ............. ...�..,.... .,. _ . . �...,.......:. .....,........ .,.... . �Signafure of Permittee Dafe . , , SEE REVERSE�FOR EXPT7fNATOkY CA�JG(JAGF . � „ � • �..:��:y :da�na��.,>.. �,:a��,i"�...t�.�., e�,.2?��",�'Yi���':,p �r_ ��p��. r a..s"�r-..,- w'�„`.�;.ax � , �. � ��"as3sv�C�o�'s►�7E5 . +J�tt��I�3�}F r1EC�.�12l�'�°I6�1� . �.,. ��.;� �.. -; '� � ....,- .......,__. „ , ..._.. . ,.,,�...... . �i�,�i:� ,�,....�.,. .._ } . . ..�,.... , ,.. �a����VA�.S ,< ..�� .. .. ,. , . --.-------- — .. ..... . . ....... �.,. .. ._.� .w. .. 4hee•eop�`ir:�:�ailsase�n¢ feog+See�.ontracfax's i]ATE�.: 11VSPECfOR'SSIGNATURE ' ' . . . r�—�—�--� ..., , . ,.�. '.°.--,..••i,it2RSe fi.BW 1SOY'Y�IE�0�4W1�Y2i.5U"�u n6�O14%��Z.Jr. � wEwHousesev:ea ' l�s�� �m�� ' �usimeax azad,PraJessfotrs Cod'ef A�y cis`y-os catrira,r� , �� .. ,-�---- — — . �. . ....- - . , :,...... .'•:.:.-: ."'"'.'.",....r,vbirh re�uires¢�7erzxst:eo.arsEf^'.ul,�xBBer. �sroprna3ce, . . mNNECf ADORIONAl . . .�� � � � . �... , . � . • � P:to 98S 5S5 985¢0 ' BUII�ING OR WORK' __ d69AOdG5h'17fi T¢�IF$t:d44,y+siJkCLV6PB..�'`SO � !t0 :. .. ........,._.. ' SEMIC TANK,SfEP.VIT�51 � - . .• ..._ ................. ._...... . '....�. , ... '�l6dSS1 76QtL9Pta' �Je#�gi6Y1i1#�99'S4iC11 Q8TSf3 i�5�e E[t . AND/OX DRAINFIEl6 _ .. S8�9i&Ef SkiBCX88NY .'�JCL',r93 1'8�8C89&6£(�'}��f'EPd6M14E EO $�7G' � __.. s . � assroo�.❑ umveu�. . ..._ . ..,..•:,,,��. .._.....,n.. ..��„�....., .. ��,a.,.:..,.. �.... . :..�mvis3��uj tbe Coshxscior`s�u�rue::aau�Cbagtar 9 _..._________— ..... ...:...,., ..�.�.._(.. (conamnasr3ci�g sveeS Ser�sns:7�00)of's3s`vLsiar.3 0}'t#�e AITER,RFPAIR.SEWER� . .� .. . .. . .._... � ' « ..� SEWAGE DISPOSAt SVSTFNi � _... BYYf�f�fiidSi&?�3Yt�.PTL,J�Bd`3i09A3 �.OfeBf Gs^23J6t.48 i5¢i¢Hi�B 38Y � ' DISCANNcCi PtUG At�D . . . ..- . . . - 'P}JL"PCJTDWb BAl3'nYtB'd&iYS,�OP 1�38 i5d�{d'g'C!L 8.9G�.'9:d�t%tI:C..�YS$ � ABANDOYHOUSESEWER . . ......._..._..._.__,:..:.. ........�.:.:...ax,:.�.� .�..._.;-"..^::!:"::.`.: g1EoI6dl0iRL}`SBL'�'1dJ��I.7f1JAri�j"GpQ�iCGfAo',f�l'iT3�E9ri3fi '_. 3.1'CKFILL5E9TIC TANKS❑ �: " Ot iU�s78 SI16:t �y . SEEP.PITIs)L� CESSPOOLS Q.,,��¢- � ' — ... _..�. �... ��.. -:L.e -_ V.._,. s�bjects tbc aitj�a'atan:�n a rdvdl�stocl€y� .a . ,.,..,. . ...M�. v �.._..� .�,�. .--:.,, .^x�,:z�t�. *r +,+ �r wY��.�.-. 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