HomeMy Public PortalAbout5118 ROSEVALE DR_Sewer__ WORKERS'COMPENSATION DECLARATION ��rr
hereby offem that I have a,Cerbficate of consent to self /
laaurd, or a certificate of Workers Compensation Insurance or 7a^°'� a•, '
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PCRTfg4 d het f ( 38 C ) , ; ,— Q mom'"" B/BT' APPLICATION FOR PERMIT
❑ ertlfled copy Is hereby furnished SEWER - SEWAGE DISPOSAL
CCertified copy 1s filed with the county building Inspection BUILDING AND SAFETY
department C /� / -
DateT:9 o— Apphcati„IS f,6l +'�--�r FOR AP (CANT TO FILL CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERSBUILDING L
COMPENSATION INSURANCE AppRLSS a STATKJN T� r DEPTH
(This section need not be completed If the work Involved by the Locum AvuasolE REFEREra . "T L R
permit Is for one hundred dollars ($IOD)or leas )
I certify that In the performance of the work for which this CROSSNEARE / a_.o TM����ION DLTMP
CR065 ST Y DORS P l ML i0 P L
Permit Is Issued I shall not employ any person In any manner
so as to become subject to the Workers Compensation Laws �, R CO LIN, NO �OB!"OO
MAUI TRUNK PERAVT NO ROADPFRAVTNO
Date Applicant ADoaESS
" ARIDAVIT WANER
NOTICE TO APPLICANT If, after making this Certificate of EASEMENT RECORD INSTR NO DATE
ON i�rE/h_ TEL NO ^fi/�
Exemption you should become subject to the Worker UGAE
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO
HWY OR ST WIDENING
comply with such provisions or this permit shall be deemed
revoked TuoclL TRACE COSTATE ENCProgoIMENr
LICENSED CONTRACTORS DECLARATION OP tRncs PERnur No
I hereby affirm that I am licensed under Provisions of Chapter SIZE OF LOT �C,��/ Now ON'Or
9 (commencing with Section 7000) of Division 3 of the Buss- USE OOF CHMGES
nese and Professions Code, and my license Is 1n full force and
effectCONTRACTOR CONNECTION CHARGE
License NumberyyZ11LIC,
Class �E ADDRESS REIMRSBUW PEE O
Contractor DotO Z r � DISTRICT NO GROUP • MAP PROCESSED BY V
C"
BK
El am exempt under Sec of the L A Co saHSE NO Ile uss O
Plumbing Code and/or Sec ofthe NO I
PUBLIC�RPTION WORK FEE HNu VALID ION d
HOUSE SEWER CONACTWG TO /1 DATE
B B P Code fort follow recision SEPTIC TANK SEEPAGE PT OR (/ PIN =
PTS AND/OR DRAINFIEID
Dote HOLISE MIA.SEWER CONlECTING TO 5Y /
Signature CONNECT ADDITIONAL 5103 OR
ER-8 R DECLARATION WORK TO HOUSE SEWER
I hereby affirm t I a xempt from the Contractor's License IELD
�CssPPOOPAGEOLL DRY EL NVX*+ tE
Law for the following reason (Secton 7031 5, Bulsness and Pro- SEWER REP R O At ABANDON
�g �6 4 Q 9 A
fesslons Code)
❑ 1,as owner of the property,or my employees with wages as # is • • • 10
their sole compensation will do the work and the structure
Is not Intended or offered for sole (Section 7044, Business Permit S I • • 27.50
and Profenlons Code) OWNER'S
❑ I as owner of the property am exclusively contracting with AUTHORIZATION TOTAL FEE • • • 2 7 5 06
licensed contractor to construct the project (Section 7044 1 HAVE AT NIS DATE A CONIRACr WITH THE HEREIN NAMED CONTR croR iso
Busmen and Professions Code) CONFECT THE ABOVE DESCRIBED EXISTING DWPUNG M THE PUBLIC SEWER 0 1.27-87
CONSTRUCTION LENDING AGENCY ,
I hereby affirm that there 1s a construction lending agency SIGNED THIS DAY OF 19_
for the performance of the work for which this permit Is O'''''EROR
hued (SBC 3097, CIV C ) OWNERS w
ADDRESS
Lender s Name
Lender s Address
1 certify that 1 have read this application and state that the
above Information Is correct I agree to comply with all County
ordinances State regulating Plumbing and Sewers
and h
israWAuthm. a esentatives of this County to enter
uponthe ve ntlo d property for Inspection purposes
jz' _L7— /
oture of P lttee Dote SEE REVERSE FOR EXPLANATORY LANGUAGE