HomeMy WebLinkAbout3817AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificote of consent to self
insure, or a certificate of Workers' Compensation Insurance, or
a certified cggy )hYRWEI00,_4ab C.
Policy No. o1Wt ny Hartord Group
Certified copy is hereby furnished.
Certified copy is filed with the county buil ng in etti n
departm nt.It
Dare Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This section need not be completed if the work involved by the
permit is for one hundred dollars (SI00) or less.)
1 certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Dale Applicont
NOTICE TO APPLICANT: If, offer making this Certificate of
Exemption, you should become subject to the Workers'
C- nsation provisions of the Labor code, you must forthwith
Il with such provisions or this permit shall be deemed
Iv.J ed.
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter
9 (commenting with Section 7000) of Division 3 of the Busi•
ness and Professions Code, and my license is in full forte and
effect.
License Number 40961111 Lic. Class R
ConlrocIcHBramal ea Cali fDoI.
I am exempt under Sec. of the L.A. Co.
Plumbing Code and/or Set. of the
B. & P. Code for the following reason
6
Signature
O NER-BUILDER DECLARATION
I hereby offlrm that 1 am exempt from the Contractor's License
Low for the following reason (Secton 7031.5, Buisness and Pro-
fessions Code):
r 1 as owner of the property, or my employees with wages as
teir sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business
and Professions Code).
I, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Section 7044,
Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued (Sec. 9097, iv. C.).
Lender's Name
oronto Canadian Bank
144 Sans6ffi St., Suite 700
Lender's Address
I certify that I t i>!n I at rhe
above information is correct. I agree to comply with all County
ordinances and Stole laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upon the abo v mjn/(yone d op t for inspection urpose
WSign re of Permittee D a
76A6Q0
CE BOB (REV. B/BT) APPLICATION FOR PERMITE
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN CONNECTION DATA
BUILDINGABORE55 Fact Thitindpr Jrai] STATION DEPTH
r24445
LOCALITY Diamond Bar MANHOLE REFERENCE UPPER
ROSSSST. Hed TYPE OF CONNECTION LENGTH FROMOOdY. CURB P.L. M.L. TO P.L.
Bramalea Limited P.C. NO.
OWNER CO. IMP, NO LOB NO
3 5 i rway Avenue, Suite N TRUNK PERMIT NO. ROAD PERMIT NO. ADDRESSADD
CITYCosta Mesa TEL.r,a. 714/850-1001 AFFIDAVIT WAIVER EASEMENT RECORD. INITR_ NO, DATE
EGAL 29DESCRIPTIONLOTNO. HWY. OR ST. WIDENING
BLOCK TRACT 42568 STATE ENCROACHMENT
NO, OF YDGS. PERMIT NO.
SIZE OF LOT NOW ON LOT
USE OrBUILDINGS None OHARUS
CONTRACTOR Br4malea Calif.CONNECTION CHARGE TEE
ADDRESS 1lql Airway Avenue, RSEMENT rfE
cayCosta Mesa TEL.No. 714/850-1001
DISTRICT NoGROUP MAP PROCESSED BY
CC.
BLICENSENO409610CL
BK PIG
1 U /Z3
NO. DESCRIPTION OF WORK FEE FINAL
HOUSE SEWER CONNECTING TO
PU&IC SEWER oO DATE VALIDATION
SEPTIC TANK, 5EEPACf PIT OR FMAIPITSANVIORDIIAMeeLD
HOUSE SEWER CONNECTING TO BY
PR4VATE ESYSTEM
SEE REVERSE FOR EXPLANATORY LANGUAGE
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