HomeMy WebLinkAbout2217WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a cerlificate of consent to self insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, lab C.) Policy No. Company Certified copy is hereby furnished. Certified copy is filed with the county building Inspection department. DoA/26/87 Applicant Van Diest & So—, Inc. 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 ($IDO) or less.) I 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. Dote Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject tothe Workers' Compensation provisions of the Labor code, you must forthwith comply with such provisions or this permit shall be deemed revoked, LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full force and effect. License Number 376814 Lic. Close C 42 . Contractor Van Diest & Sryt Inc. 8/26/87 I am exempt under Sec. of the L.A. Co. Plumbing Code and/or Sec. of the B. 8 P. Code for the following OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Secton 7031.5, Buisness and Pro- fessions Code): I, as owner of the property, or my employees with wages as their safe 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. 3097, Civ. C.). Lender's Name - lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all County ordinances and State laws regulating Plumbing and Sewers, and hereby authorize representatives of this County to enter upon the above-7tentioned properly for insp tion purposes. Signature r Permittee Off. 92 00D2 DPW 9/87 76 6e2 APPLICATION FOR PERMITss SEWER - SEWAGE DISPOSAL COUNTY OF LOS ANGELES BUILDING AND,SIii FOR APPLICANT TO FILL IN Z CONNECTION DATA STATION y- S DEPTHADDRESSame LOCALITY Diamond BarMANHOLE REFERENCE7 UPPER NEAREST TYPE OF CONNECTION LENGTH FROM CROSS ST. Y. CURB 2- 1. M.L. TO P.L.S OWNER YYYU+yon CO. IMP, NO. P.C. NO. JOB NO. / MAILADDRESS TRUNK PERMIT NO. ROAD PERMIT NO. AFFIDAVIT WAIVER EASEMENT RECORD. INSTR. NO. PATE CITU TEL. NO. LEGALDESCRIPTION LOT NO. HWY, OR ST. WIDENING BLOCK TRACE 44824 TVSTA TE FNCROACHWNT NO, OF BLDGS. fAE PERMIT NO SIZE OF LOT NOW ON LOT USE OFBUILDINGS CHARGES Ind.ARGECONTRACTORaDiest & S{{o FEE ADDRESS 1494 Hamner Ave # A FEE GROUP MAP PROCESSED BY CITY TEL.NO.714-7449 SATE 681 cass C 42LICENSENO. NO. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO PUBLIC SEWERISEPTICOVALIDATION TANK, SEEPAGEPITORHOAND/OR DRAINECTIHOUSESEWERCONNECTING TO PRIVATE IEPOEAI SYSTEM TCONNECADDITIONAL ORWORKCTHOUSESEWER OVERFLOW SEEPAGE PI , LMA INFIELD EKTN., CESSPOOL, DRYWER. MANHOLE ALTER, REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM 4221. r" OWNER'S Permit a 1 p AUTHORIZATION TOTAL FEE DS 2.81-87 I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONYRdCi7R YO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE rustic SEWER. SIGNED THIS DAY OF 19_ , OWNER OR OWNERS AGENT ADDRESS SEE REVERSE FOR EXPLANATORY LANGUAGE M t SA y T D4 fG Da i.,b fv M. Z p M. Zo z o^n n Z C)aI b 0 SA y T D4 fG Da i.,b fv c$ Z m ^ ", pQ ". o `c N O G v. M `•: ° a w C• GV" N Zo z o^n n Z C)aI b 0 OZ D C: A m9 po O 00 piQ-ti ^ bGc`hn'•°+i°`n., SnD A Ojj Ov A O A x;77 N tr i .". _ moo ., L... T„•" w o ':L N V» ti b Q r O y 1 D m OAN N_ D CA b o = ai Rbc+ H^• .Cnb'"., ^ . a" o'e.^.n" C`°:°•10'Oc O=fid i.,b Cr m ^ ", pQ ". o `c N O G v. M `•: ° a w C• GV" Ql• O O• A• ' NAG 7 • O" O '• L .'i. S' L }• O fi L C 'Cbf: n O 0.b : M ry ; R. M ; b 0 t~n' L' r ti• o A^ O p '•. D N. o' n G c N .`.' N d 14 O piQ-ti ^ bGc`hn'•°+i°`n., V Q.•.1 (!q O C n n `'• • a. • l x;77tri .". _ moo ., L... T„•" w o ':L V» ti b Q r O y