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
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