HomeMy WebLinkAboutNo Permit Number WORKERS'COMPENSATION DECL4RATION ��
1 hereby affirm thoi I hare a certificote of conseN to self o7.000z orw veT � ' �
inauro,or o certiiicate of Wofkars'Compenwtion Inaurance,or �6Pi°'�D �.
a ceni(ied topy theroof(Sec.3800,Lab C.) "� � APPLICATION F4R PERMIT
Policy No. Compony 0s
❑Cer�ifiad mpy�,�e�eby f�.���tisd. �. SEWER - SEWAGE DISPOSAL �, �
�Ce.tified copy is filed wi�h the tounty bui�ding impeu+on � COUNTY OF LOS ANGELES ' BUILDING AND SAFETY � .
deporl '
��/f38 Van Diest & So3� In .
Date �4ppl�conr � FOR APPLICANT TO FILL IN •. 2, Z CONNECTION DATA
CERTIFICAiE OF EXEMMION FROM WORKERS' ��ip�� . �
COMVENSATION INSURANCE �oo�ss 281. lecr St � ST^"°''' D o[vtH �
(This sec�ion need rroi be comp{eted if the work involved by the ip�Aiin D12P10Y1CZ $�T M^.r+Ha[xerert[Nce �
permit is for one hundred dollon(EI00)or len.) � ° 3 S R
1 certify tha� in the performance of the work for which this "�'E„o"SSsSt rY�cacoN.,Ecr�oN �r�THFao� .24
permil it iu�ed,1 aholl no�employ any person in any mpnner
�. Q1RB , v. M.L.TO P.l.
so as to become su6jec�to the Workera'Compensation Laws. O,NNER i'�IDLyOIl CO. � m.w�v.No. ioe rN+�o. 0
��� - TRUNI(PERMITNO. ROADPERMITNp.
Daro Applimnt ^a�u . . . �
NOTICE TO APPLICANi: If, oiter mokinq this Certificaie of rafioavn wa.rvert ease,w[r+r RECpRp.INSTR.NO. OATE
CITv TEl NO.
Eaemption, you sho�ld become suhject to rhe Workers' iE�Ai
Compensarion provisions of the 4abor code,you must for�hwi�h oEscaioriow lOT NO. NWV,pI 5T.WIDENiNG
comply wi�h such provisfo�s or this permii ahall 6e deemed /
revoked. eiocK TRA[i 20� � 37A1E ENCROACHMENi
IICENSED CONTRACTORS DECLARA710N r�o.or e�oos. � �RM+r'uo. �
S12E OF LOT NOW ON lOi � ^
I hereby affi�m thar I om licenaed under provisions of Chapter ut�a � G �
9(tommencing with Sectioa 7000)of Division 3 of the Busi- �iipir.�s cHaeces
neu ond Profefsiont Code,and my litense is in f�l)force ond �
effect. � �pNTRaRpR vuSl �l@6t � SO:1� T17.�.�� [ONNECiION CHARGE fEE �
License Number 376814 lic.Closs C 4� nooa[55 � jj�In r f Y xciMeuasEn�Nr r�¢ . o
COnhOt10� �� �e$t �Oi9 �/v1�8 OTY T'��l'CO TE�� 73G_7�n2 DISTRICiNO. GROVP MAv GNOCESSEDBY (J
&( PG �/,�� Z
❑I om exempl�nder Sec. of fhe L.A.Co. iiceNse NO. [iAss � � `�"LLL— �
T-r�
Plum6ingCodeand/or5ec. ofthe NO� ����T�� �K �E RNAI U
wa.ic��Rmrw�cnracro �7 p� onre VALIDATION a
B.8 P.Code for the following reoson �'�j �
SE IC iANK.SEFPAG[PIT OR fINAI Z
PItS ANP/pQ pRAililflP
Dofe NpUy$EW[R CqJKtTItVG t0 Bv
PRIVAT D! V M
Sfgnaturo tarN[et wboinow.i uoc.ae ,
OWNER-BUILDER DECLARATION �K ro"°�s[s�`vFR .
tOW SfEPAGE PIT.ORMNfIElO ,_9� '�.'7 F�
1 here6y offirm thot I om e.empt from the Contr«tor's Licanse F%TN.,CFSSPOOI,DRYN/El{ AMfrNOlf
law for fhe following reason(Secton 7031.5,Buisneu ond Pro• niTee,a[v,a�R bw.na�.r�poN�qus[ . �'• • ,� a
fCS5i0�5 COEQ�: SEWER OR�ISPOSM SYStEM
❑I,as owner of�he property,or my employees with wages os � e e i 7,S�
their sole compensalion,will do fha work ond fhe sfructure
is not iMended or offerod for sale(SeUion 704t,Business e o •G.l.��.,.�
and Profeuions Code). OWNER'S Permif S 1� 50
❑I,os owner of the properry,am axclusively contracting with AUTHORI2ATION TOTA�fEE U��Ci_c�
licansed conlrottors to co�slrutt Ihe projecl(Seclion�44�, I HAVE AT tNiS DAif A CONTRACT WIiH THE MEREIN NAMFD C6NTkACiOk i0
BVSine35 and PfofMsiOns�Ot�l�. CONNECi THE ABOVE DESCRI9ED E%ISIIMG DWFIIING i0 THE W1BlIC SEwFR �
CONSTRUCTION LENDING AGENCY ,
I haroby affirm �ho� �Frore is a conahuciion lending agancy S�GNEDTHIS onvo� iq_ ,
for ihe performance of �he wo�k for which this permit is �'NERo°
pWNER$AGENT
ISSUlC�($et.3��.Clv.�.�. � �
lander's Name �REu ��
Lendm's Address
I cenify that I have reod rhis applico�ion and stare that the � � �
above infwmarion is correu.I agree to comply wi�h all Coun�y . .
ordinances and S�o�e laws regulpling Plumbi�g and Sewers, � '
and bereby oufh �ize represeMolives of this County lo enter �
upo the above- enlioned properly for inspection purposes. -
� O�
Signature 4 a�miflee Dal SEEREVERSEFORE%PLANATORYLANGUAGE
tsi:P.tto2'S t:oT�S O`VNER-IIUILD�R DECLFiIIATION
APPROVALS onre wsreaoa�s scrwnl¢e I hereby af(irm that 1¢m exemp[from the Contractor'e
. .. -�Litense Law fur the lollowiog rcason(Sccticx 7031.5,
NEw t+ovse 5tw[a ��(', �� Busiwets and Professians CodeJ:Any.city_ur ruunty
couu[anooinorm.� . � , • ' .- wbicb�reguires.a pern:it to construct. cltcr. i.r.pmvc,
euimiHc oa woaK � demolisb,or repair any strectare,prior to its iss�aance,
SEPTIC TANK,SEEP,PIT(5)
AND/ORORAINFIEID S'�• � � � . OttO fCgZ'tfCt If'iC cppltcanr Jar sucb J%�rr.:it �D fire 6
Cc55aoot ❑ oarvhu O � . �� . .�� ti,�r.ed ttatement 1Lat Gc is licensed purruar.t to tbe
_. .. yroursions oJ tbc Contraclori Liccrua I�f:.�(CLaf�tcr$
ntrEa,a;vAia,s[vhR oa . . � - -� (commcnting u•etL Scction 7000J of Dirision 3 oJ tGr
SewnGe�isw�s.ni svsrern Dusirscss and Professront CoJeJ or t1:a:Ge is exemf�t
PiSCOr+NeC7 ttve avo . '- --� - � tl erejram and tFe daais jnr tl�c alfr;ed cxenri iior„Ilny
ABAND04HOUSESEWfR. , , '
&4CKfILt SEPTIC TANKS❑ - - � t`/O�titf0/i Of,SCCtIOn 7031.5 by eny�p/�IiCJftt fnY 4�ieTlnfl
FEEP,PiT(5)❑ assaoats p subjetls tGc appl:cant to a eirilpcualty a/raof morc thar.
- � � -� � five Lundred dollars(SSOOJ.: -- � - � �
� , � ❑I,as thc orrner of the proyerty wilI do the cvo:k:and
� . . . _ _ _ �_� � � � �� the structurc is no:intended or offcred for sale. �
(Sre. 7044,Batiness u-d PmJestin7v Coder Tbe Con-'
_ . . . .. - . � � tractor's Lrcentc lau�docs not opyly to c�r. o:cncr of
. � - � � ' property mho buiG?t ar iniprnves tbereon,er.d wl�o docs�
� � � - - tueG iuork bir.;tel`proridrd t�a�n:ch�inrf+rox�em.ent;
� � , .. . . i '. � � � ore not intended or ofJercd for aelc.lf'Gocrver, tLc
. - . .. . building or inafirot�rn�cni i.c sold u�itbir, oe.c ycar of
- � - � � eompletian, tGe otunervbuilJer wi11 banr tLe bcrdcoz
. . . . _ - _ . . . . oj provia�lhn:bc did not Euild-or in:�roec for lGe�
, purpore oJscic.J �
_ ` �— I am exempt under Sec.' ,
��. B&P.C.for this reason
Date
Or�ner
INSPLCiOA'S NOTES � ' �
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