HomeMy Public PortalAbout5120 ROSEVALE DR_Sewer__ WORKERS' COMPENSATION DECLARATION
I fheTBby.64,,m that I hove a cemficate of consent to self
msy[e ''or a certificate of Workitri Compensation Insurance or
Pa mal L*2r Yh C;mpon OD �� s y=„f4,,,;Q 0;�1 RIN "tt APPLICATION FOR PERMIT
El Certified copy Is hereby furnished SEWER - SEWAGE DISPOSAL
LQ{ertified copy is filed with the ounty budding inspection i� UILDING AND SAFETY
depanment
Dote /-11u� Applicant FOR APPLI TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS WRUNG
COMPENSATION INSURANCE ADDREss STATION :2. L DEPTH
(This section need not be completed if the work Involved by the LOULIry MAfW(XE REFT:REFF� / ,I
permit is for one hundred dollon ($;DO)or leu ) s tj N• L
I certify that in the performance of the work for which this CROSS TT ttRwmrvNJECTIaN INaGTH wogs
Y NRB P ML TOPL
permit is issued I shall not employ any person in any manner
so as to become subject to the Workers Compensation Laws oLy�p co IMP NO POB No
'WA'IL
Dote Applicant TRUNK RRMIT NO ROAD PERMIT NO
ADDREss
NOTICE TO APPLICANT If, offer making this Certificate of �, --x/t��„ R1 NO . A IDAVIT WAIVER EASFMEM RECORD INISTR NO DTE
Exemption you should become subject to the Workers' Is
Compensation provisions of the Labor code, you must forthwith
DESCRIPTION LOT NO 2. FBVY QRST W KING
comply with such provisions or this permit shall be deemed �F
revoked BUOt TRACT / STATE ENOtOAC w
RRMrt No
LICENSED CONTRACTORS DECLARATION 317E OF LOT NO OF BLDGSNOW ON LOT
I hereby affum that I am licensed under provisions of Chapter ��
9 (commencing with Section 7000) of Division 3 of the Busy USE OF al
nem and Professions Code and my license is in full force and
effect µ./y'/-!�((""'���yy��� /� CONTRACTkVJ ��
CONNECT CHARGER 1
License Number y/ L r —L¢ Clan !
,,►►�� �� � � ADDRESS 1
Contracto/L�fd A-06 - Date / �7 T Crtr Rl NO DLTTRIcr No Aw PROa55m Br V
A BK Z
❑ I am exempt under Sec of the L A Co L�rNSE No aASS (� �d� /' _O
CAI
Plumbing Code and/or Sec of the Pao RIPE OF RK RE RNn1 (O U
HOUSE SEWER CONNECTING To Q DTE VALID ION y
B & P Code for the following reason PUBLIC SEWER to
SEPTIC TANK SEEPAGE M OR
PIIS AND/OR DRANJFIEW RNAl
Date HOUSE SEWER CONNECTING TO BY
PRIVATE /
Signature CONNECT ADDITIONAL 5= OR ►
OWNER-BUILDER DECLARATION WORX TO HOUSE SEwER
I hereby affirm that I am exempt from the Contractor's License EXTN �CESSroa oPrvwE�IiiuiFWiaE
Low for the following reason (Secton 7031 5, Buisness and Pro- uTER REPAIR OR ABANDON HOUSE R 6 4 1.0 A
fessions WE
Code) SER OR DISPOSAL SYSTEM
❑ 1,as owner of the property,or my employees with wages as # •,• • e 1 0
their sole compensation, will do the work and the structure
is not intended or offered far sale (Section 7044, Business I e ! 2 7 5 0
and Professions Code) rAtUTHoRmAnollill
S Permit f
❑ 1 as owner of the property,am exclusively contracting with TION TOTAL FEE • e - 27506
licensed COnirOCian t0 construct the project (Section 7044, TE A CDNfRACI WIiH TILE I[REIN NAMED CONTRACTOR 10
Business and Professions Code) E DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER Q 1.27-8 /
CONSTRUCTION LENDING AGENCYI hereby affirm that there is a construction lending agency DAY OF 19for the performance of the work for which this permit is
issued (Sac 3097, Civ C ) OWNERS AGENT
ADO E55
Lender's Nome
Lender's Address
I certify that I hcv ead this application and state that the
above Informatio I correct I agree to comply with all County
ordinances and t to law gulating Plumbing and Sewers
and hereby o roe ntanves of this County to enter
upon the abo/ men n property for inspection purposes
Si re of Perol6e Date SEE REVERSE FOR EXPLANATORY LANGUAGE