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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 � � �