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HomeMy WebLinkAbout1563A . .. ,...�,�. z:;�.�..,_.___.� � - -- WORKERS'COMPENSATION DECLARATION . �_ � � . � � ' � . . I hereby offirm that I have a certificote of consent to self msure,or a certificate of Workers'Com ensation Insurance,or /�o e �^ a certif e o eof(Sec.380Q}ab C.)�nd...... .. . .. ... ,.... IV,P1.'�rA�fO.i�l �O.R PER,M.IT `�. � � � �. �. p an CE 808:REV B'Bl� PolicyNo Company�T. ,�s . ,.., . . . C . ... ❑Certifie c a hereby fumished- - _ . , � � - . .�,51NEI�...- SE11,1(qGE piSPOSAI ..�� �, �CertiFied mpy is filed with ihe county bwlding�inspeUion .._,. ..,;-. . . ;„.. CQU,�T�.Q,F I,�1S G�LE$ ..,BUILDING�AND SAFETY , ��.,:. ... deparlment. - �..� �. . . , a i.. , . , �..-.�� . . oo,e 8 20 C Applicant T. �'reeman FOR.APPLICANT TO FILL IR! CONNECTION DATA CERTIFICATE OF EXEMPTION fRpM WORKERS' eueorvG � � COMPENSATION INSURANCE ncoeess 'y�< srnrioN oearN � (This sectian need not be completed if�he work involved by the io�AUTr DII�.� BAR �a.NHo�E REFERENCE UPPER . permit is for one hondred dollars(5100)or less.) � wER . � I certif ihOf in fh@ NEARES� - �.p f iVGE OF CONNKTIOM1 LENGTH FROM � y performance of the work for which ihis ceoss sr. �j� Y. cuae a.i. r�.t To P�. ' � permit is issued,I shall not employ any.person in any manner - �. so as to become subjeci to}he W.orkers'Compensafion Laws. . ?.C.No. . OWNER CO.IMP.NO. JOB NO. O� . �'� PO �X J�G� 'RUNKPERMITND. ROADPERMITNO. � Date Applicont noortEss NOTICE TO APPLICANT: If, afler making Ih15 Certificate Of `�Ty ry r� AFFI�AVIi WAIVER EASEMENT RECOk�.INSTft.NO. DATE . . IiOV�.,T1C�I. TEL NO. ( " �mption, you should become subjeU 10 the Warkers' � �pensation provisions of the Labor code,you must forthwith DFscairt�ion� �oi r�o Hwv.Oe si.wioewNc "Ce'mply with such provisions or this permit shall 6e deemed 35754 � � revoked. e�crx iRAR $TA7E ENCROACY.MENT � �� LICENSED CONTRACTORS DECLARATION r+a OF etoGS, veaMir No. _ I hereby offirm fhat I am litensed under provisions of Chapter 5¢eoFior riowon:�oT . 9 commencin wifh Section 7000 of Division 3 of fhe Busi- ���� p � �� � 9 I 6UILDINGS ��.YL O 1LP.r`�� CHARGES ness and Professions Code,and my license is in full force and yl'�^� ,�n /�� /�/'��T[�m � �� , _ effecl. r� CONianCTOR l:i��JX��t3F� 1/yLy�J 1 o COMNECTION CHARGE iEE � License Num6er ¢7�88 r Lic Class c34 p � ' p n ADORE55 r„�2� RE�MBURSEMENT FEE � , COf11�qC10� �• Fr.eemar}�Piy y/GOf$� DISiRICTNO GROV� MAP �40CESSEDBV V �. CITV 'EL.NO. BK PG Z ❑I om exempt under Sec. of ihe L.A.Co. uCpNse uo ctn5s �� � � Plumhing Code and/or Sec. of the N�� DESCRIP�ION OP WORK �E flNa_ V� IqJSE SFWER CONNECiING TO �A:E VALID TION � B.&P.Code for the following r.eason Pue�_ic SewEe ]. Q �r—2 l'^�b y SE�'IC iAtiK,SEEPAGE?li OQ FINA1 � � vli5 ANO/OR DRAINFIELD Date HOUSi SEWER CONNECiING'O 3Y _ � ' �� PRIVATE OISPOSA:SVStEM - �' . $i(,]r10fule COUN�'.i A�DITIONAL BLOG.OR � ' � �� OWNER-BUILDER DECLARATION woex To House sewee _. _ � . . , � . . I hereby affirm Ihat I am exempt from the Conlractor's License �zTN�LOessrooiGocrw��iAMnriHo�e , � ���•��� � � Law for 1he following reason(Secton 703'..5,Buisness and Pro- .nLrEx,aEpqiR oR ABANOOw t+0u5E � - � � � � - �� . �� �� �� � . ' � �IO�S COdEJ: SEN/ER OR DIS�OSAL SYSIEM � � � : � "�I,as owner of the properry,or my employees wifh wqges as .I . G�v C , their sole compensafion,will do the work ond the structure . � - � is not intended or offered for sale(Section 7044,Business � ' � ' � �� � � �;_ '. , . and Professions Code). OVIINER'S Permit � I �j� ' _ . . L+o ❑ I,as owner of the property,am exdusively coMratling with AIJTHO,RIZATI�N TOT/�1L FEE '�7 � � 4-�>`t;w.�b . . �ICenSed contraclors to construct the project($eCflon 7�44, 'HAVE A�,THIS_DATE A CONTR.4CT W:TH THE HEREIN NAMED CONiRACTOR TC �� � � � ' �� Business and Prqfessions Code). mtinEcr rnE neov �ESCRIeED EXISTING DYJEILING i0 TF1E PUBUC SEWER. � � ' �' � � CONSiRUCTION LEN�WG AGENCY 2� �__�g $6 ' � � "; � � � . " ' I hereby qffirm fhat fhere is a consiruction lending agency SIGNEDiH15 A OP 19_ ► � � , .� , OWNEROR ... . ....�, ,,..... .'., ....:. � ,..... for the performance of the work for which this permit is ownee5n�enT ' � � � issued(Sec.3097,Civ.C.). F.eC Sq�pO �•,�s ,(�,�a �$ . . � � - � ' � ...� � ..� -� ADDRE55 . . . � Lender's Name ��� � � �� � � ....., L.eode,r:s..?�ddress ... . . .:�, ..�..�. "-�� '. ,: � :' �.. :'_ "` ,'' . - ' -.. � , . I cerfify that I have read this application.and stpte.that the „ � �� �� '� � . � . - � '- ,.abAve.information is correct I agree to comply with oil C,ounty � ��. . �-�� `�- .�:�!� � . , � � � � '. -' ' , - '. ordinances and State laws regulating Plumbing and Sewe�s, : . � ' ., � � � � � � . and hereby authorize represenfatives of this Counry to,enler " � � . ' . . .. �.. u on he abov eNioned property for inspe�n purpBses, .. �� . � ' - . � � � � . gnotyreofP@�iJt@e_,,._._.........._Dote� ' � _. �,. 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