HomeMy WebLinkAboutNo Permit Number WORKERS'COMPENSATION DECLARATfON q1moZ pow��ei . � � �
I here6y affirm ihat 1 have o ce��ifito�e of consen� lo self �aaeea� .
insuro,or a cen�ficate of Workers'Compensolion Insurance,or �E�e �APPUCATION FOR PERMIT
a certified copy theroof(Sea 3800,lab C.)
Policy No. � COmpony � �� SEWER - SEWAGE DlSPOSAL � �
❑Cxtified copy is heroby fvmished.
�Ceriified topy i�filed wi�h the coun�y bu�ldmg inspeciion - COUNTY OF LOS ANGELES , BUILDING AND SAfETY
deportment.
pa�e 6 88 Applico�t Y� Diest �C Son� Inc. FOR APPLICANT TO FILL IN O-f O CONNECTION QATA
CERTIFICATE OF EXEMPTION FROM WORKERS' eA��a+c 2a2E� I:.-'��,2CCY•@�t Pl. srnt�oN , ��" �
� COMPENSATION INSURANCE
(7his section need no�be comple�ed if�he work involved by the i�iiTY . ' awr��at[weFCReNc[
permir is fw one hundrec4 dollars(Sl DO)or leu.) r.�aREs� �rP[oF ccnr+cCnorv tEr�crH Faon+ �/
1 certify�hot in the periormonce of the work lor wh�ch rhis o+o;s sr. r. cuae v.i M�.to r.�
permil is iasued,I ahall no1 employ any person in ony manner v.c r+o. /�
ao os to 6ecome subject b�he Wo�kers'Compensolion lows. OwNea j'?� i Qri m.inw.No. �oe ra. C/
MAII � TRUNK PE4MIT NO. IIOAD PERMIT Np.
Dote Applica�t woo�sS � �
AFFI�0.VIT WA�VER EASEMENi RKONO INS�R,NO. DAt£
NOTICE TO AVPUCANT: If, ohsr making this Csr�ifico�e af �iTY re�.No.
Exemp�ion, yoo should bacome subject to Ihe Workers' iECAi ,� .
Compeoaarion provisions of tha Labor eode,you must forthwith o[scnivnor+ �orNo. Nwr.oa st.wioeaiNe �
tomply with wch p�ovisions or�his permir shall 6e deemad L}52b�1 � srnrE Er+caonctonENi
IC�OkOt�. � BIOCK iRACT '
� ND.OF&DGS �RMrt NO�
tICEN5E000NTRACTORSDKLARATION s�zeOf�Or NOWONIOT '�'^1(,� �– Z �
I hereby affirm ihm I am licenzed under pravisions of Chapter use oF
9(commencing wi�h Seclion 7000)of Division 3 pf Ihe Busi- eunoiNos aA�S
neas and Proiesaioos Code,ond my licenaa IS i0{UII SO�CB Oltd �ONNECSION CHARGE fEE
effa�_ co*irRanoe V�x1 D10�t Yc Son Iric. y
681 �•" 4�2 1�jQ I32.7flYl�r AVC y';: Ii ac�,vsuRscmeNrree 0
Liceose Number �� � Lic Closs ADDFE55 r
V�.T1 Dle�t 6/718g �IS�Q�CTNO GRpUv M4V RtOCE55FDBV ()
Cantraetor Date uTv 1�7 tei.r+o, – y�2 s�c � /��� 2
s'''i` 7681t� cinss C 2 Z �'`J �
❑1 am axempt onder Sec. of Iha L.A.Co. ii�Ns�No. i= �
r+0. OESCRIPTION OF V�OkK FEF ��rypi V
Plumbin9 Code ond/or Sec. af Ihe (� � W
MpUSE SEN/EF CO��NKTING TO � oo OATf �� VAUDAYION
B.8 P.Code for�he followin9 reoson auauc stwec �� \ tai�
SEMiC fANK.SffDRv'E P11 pk . FINAL z
VIIS ANO'[Ht DR4iNF�EID BY `
�a�e Y�OUSf SFwFW GONNECLING TO ' � �I v`
P4NA� 0' PL SYS?fM
Signa��re cowr.�[ct nooirior+ai e:o�.oR , .
OWNER-BVILDER DECLARATION wO°�1O HO1�'��p /�
WERFIUN SEFPAGE%t.DNa1NFiFlD . ._J � ,�i O F�
1 hereby offirm Ihaf 1 om exempl from the ControUor's license ear��.ceswax.oar.�u.m�wNoic ,
Law for 16e following�eason(Sedon 7031.5,Buisness ond Pra >�tER,pevnix oR nBa.r�Ww MOuSE �i• • •� �
fessioas Code)�. seweR os oisvosni srsrcu �,
❑1,os owner of the property,o�my emp�oyees wiih wages as � � '��.S�
16etr sofe compensolion,will do the work ond�he siruclure - i
is not inleaded w offerad for sqle(Sedion 7044,B�siness OWNER�$ Permil E '�Q� � � ��I•�C U
and Pro(euions Codel. —� ��
❑(,oa awoer of the prope�ty,am ezdusively tontracting with AUTHORI2ATION TOSAL FEE ! 2�. � �6 l Q–�P
licensed cantroctors to co�sirucf fhe project(Section�0,4, �HAVE AT THIS DAR A CONIRACT W11M iHF HFREiN NAMED CGNIRA"ipR 70
Bu5in953 a11fI PfOfQ5510�5 COCIey. CONNEC7 THE ABOYE DESCRIBED ExiStINC OWfItING TO TME PV9liC SFVIFk
CONSTRUCTION LENDING AGENCY � � � �
I hereby oHirm thar Ihe�e is o construction lend�ng ogenry SIGNEDTHiS oAvpF Iv_ .
for Ihe periormante of Ihe work for which �his rmit is owHcaoa
P� pwNEeS AGEt+T
issued(Sea 3697,Civ.C.).
nDDRE55
lendar's Nome
Lender's Addreu � �
I certify 1ho1 I have reod ihis applicoYron ond srate Iho+ihe �
above information is correct.1 agrea to comply wifh all CouNy � . � �
ordinonces and Stote lows requlo�ing Plumbing o�d Sewers, �
ond hero6y au�ho�ze represeolalives of fhis County lo en1e� , . . . . �
upo the abov � Nioned prope�ty for inapection purposes. � . .
C`� 0
Signa�ura o Perminee D e SFE ItEVERSf fOR E%ttANATORY IANGUAGE,
u+sr_cToz�s r:ares OWNER-IIUILD�R DECLAI2ATION
APPROVALS o�re ws�aoa•s sieruruce � I hereby ai(irm that 1 am cacmpt(rom th^Contractor's�
Litentc L¢w far thc follua•inr teazan(Scction 7031.5,
) N[wHC�zescvrta ���' �....� IImrinets and Professinrss CodeJ: dny eit�� or eounty
toN;.[v nooiiioNs.i . �y ' .. . . � .. . �- wLicb requires a Feva�ie to canstruc[, cf[ar,�i.^,if�raue.
eunoir+coawoeK � drmolul,or>�air any structurr,f�rior to ics issuanrc,
YPTIC tANC,SEEP.PIT�) � qll0 rcgyires tGc cp/�licart Jur SGtG PCfIi!Ji to f'Ic a
RND/OR�RA:NFiEL� •�- � � -- --�
srgned staternenl fGat be is Jicensed�ursuaat to tbe
eessvoot p oarwEu❑ � � � . provirion.c of!1 r Co;:7rador;r Lirer.sr l.cio(Cl��nter 9
atrez.c[e�ia.sevha oa �� � � - � � /cornmencing u.�itb Sec.iort 7000J of Uii�ision 3 of tl e
scwnee oisrosa�srsrent . Dusiness and Psvfessions CoJeJ or t1 at Lc is eren;ns
resCOr+�:[�nu�n�ro � El erefrm:e ar.d S4c Easi.:fnr tL•c allcgrC cxnr.ptlo».Any
AB<1lCCN N^.J�.SLN'ER �
an�riu scrne TnNr,s p � � �� - -- � - � - - - � �uioktron of Section 7031.5 by any cr flicarotfora f em:i1
stv,ertlsl� CESSibOLS❑ ' SRI)CCDS iBC 0(�AIiC6ttl fD O[YPtIQEnPI1��Of not rnorc tban
� - firo bur.dreJ dollart(S500J.: �
. � � � � ❑I,as the owner of thc pro;.ezty aitt do the u-ock,and�
� � � " the strueturc is not intcnded or o.'fered(or sala � ��
�,�� " � � _ 1 (Sea 7044, Businets ar..�!Prafcssicr.s Code: Tbe Car.-
. . . . - . �� . lrcttor's'Licease Laie does not a/�/�Jy fo ar, oumer of
� � �� �- property wbo 6uiJJs nr improae;Lbereon,ar.:l u�Ln doct
�� - � . sue6 work Gi%:sel�provided 2fic:sceh imfroacnser.ts
� ' ' . - . � � � � cro not inter.3ed o!of,jrrrJ for scl.. Il, 1.�ou�rnes, t5e
� ' � � � bailding or JmFrot�emcat u sals�u�itbin mie yrer o�
� � - � � �- � � � tvmf�letion, tLr ou•nrrbaifdcr svilf Leve !bc burJen
•- - . � - - oj provi:�g tbat Le did r.oT bii1J or im.i�rovc for tLr�
. ._ . . . . purpoie ojsale.J . ' , .. ..
� I em ciempt under Sec. - ' ,
-'' B 8 P.C.for tliis retison
Datc
- Or�ner
� � INSPECiOR'S NOTES � � �