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WORKERS'COMPENSATION DECIARATION ! I hereby offirm �hat 1 hove o certificate of coosenl to self ( insura,w a certi/ica�e of Workers'Campenwtion)nswonce,or ����� O tenified[opy thereof(Sa[.3800,Lob C.J �E eog�pEv„�, qpp��CATtON FOR PERMiT � Polity No Compony � C ❑Csrtified mpy is hereby fumisbed. SGWER - SEWAGE�DISPO&At �Certified copy is fibd wieh ehe caunry buildiny inapeoion � OUN7Y OF LOS ANGEIE��' BUILDING ANO SAfEfY department. � � �,g 86 qPplicom Van Diest & Son FpR APPLICANT TO FILL IN ONNECTION DATA CERTIFIG40MPEN ATIQN�INSU ANCE RKERS' ,pp�Eu Z �' `�u27.1 Dr• STAiIQN D(PIH (Th�s secrio�need nor 6e comple�ed�f rhe work�nvolved by rhe i«Aim I}ladIlOrid �aT ANNMOIE OfffaEHCF � UPPER perm��is fw one hundred dollors(;106)w less.{ '' NEARESi . TY�a��M�CtI�N IEtIGTN FkqN � I cerrify thor in rhe performonce of ihe work fq wbich Ihis �Rp55 sr. v, cWt6 v.t t�t.ro v,l. pgrmit is issued,i shali nbt employ ony person in any monner w ci to become subject to ihe Workers'Compensa�ion lows. p�y,�R Tk1C ��iIILj{�jD ri CO. �p iMo.r�o. �6 r o. Mnii DOtB Aftpll[ORf ' AODRE55 TRUNK FEFMIT NO.� Rpqp PERMR NO. N6FICE TO APPLICANT: If, after making this Certiticate of [rtr TE�NO NKIW�VIT wmv[e taStn�NT qECORD.INSTq NO. OATF Exemp�iort, yov should become subject to the Workers' ��u Compensation prcvisions of the Labor code,yo�mpst forthwiih �yR�m� �ruo nply with such provisions or Ihis parmi�shall ba deemed �oa5r wioeHiric � �kad. aiocK TRA�T 43162 II SiATEfNCROACHMENf . : .LtCEMSEb CY)NLRAGiIIRS OECIARAT[ON�... r+o ar�a�s. � rro. SIZF OF LOt rypw pN�pr 1 hereby affirm rhat 1 om licensed under proaisions of Chapter �a 9(commencing wirh Section 7p00)of Diviaion 3 0l the Busi- Bwmu�S 3ew. o���s neu and Professions Code,and my�icense is in full force and � effCCt. ^ ^ �pNTS�CTOR .� i� .Q. n CONNECiqN CNARGE fEE licenm Numbec 376814 Lic.Class v �G ��� � � .�. ' ' P � REiMBURS(MENT FEE � , � tr2�_@- :iV6. a� ri p, � Contracror Van Tli ��.}._Do�e�1�f8� crrv t�TOZ'CO rh.�ro. �3�-7nr�2 oisfmaruo. c�our tiuv J sseoar � � j BK PG ❑1 om ecempt under See. of�he L.A.Co. ��N��.p z f�A n �au � � /�_�/„Cr' O � � OESCRIPTIOPI OF WORK rtE �oft�•J Plumb�ngCodeand/or5ec. oHhe �pU5f5EWFRCONNECTIfJ�TO oA�i� ,�y VALIDATION � B.&P.Cade 4or the fdlowing reason °�Buc se"ER �'"�-p p, SEPTIC TM1Y..SFEiACE PIT OK N PiTS ANO/OG DRAINFIELO F�NM ^� ' �O+e NOUSE SEWER CONNECTING TO BY YRIVarE olSPOSAL SVSTE � Signmure cnru�cr anoir:oun�azpo.oa � . OWNER-BUVIDER DECIARATION `N°R"To�+ous�s�w�R OYEHFIOW SEE7AGE TT,ORAINFIEID 1 heroby oHerm�hot I om exempt from the Controcror's Licanse [xrv,cessPooe,ocvwtu,nue�Hae Law for the following reason(Sacron 7031.5,Buisness and Pw- uTea.a[raic o�i ne��moN rrou5e fB5Si0�3 Cof�9�: SEWE4 OR D�SPOSM SYSTEM . �I,os owner of the property,or my employees wirh wages as � � �_ • � { their sole rompanwrion,wi{I do the work and the strucfu�e • is 1wi inlended w oHered fof acle(SeCtion 704�,BWiness - . . .. -..�F'�F�.-"�-� :'. and Professione Code). OWNER'S Permi! f � ❑I,as owner of�he property,am exclusivety comrocting wi�h AUTbiORIZATION FOiAI FEE ' � �^"" licensed controcrora�o consrruu ihe projec�(Secrion 7044, i��A�i„�s oA.e n mrarxAtt wrtN�'+c Hcaew w.�o caara�nere To e s . � Business ar�d Prafessions Code). corrr�eci rHe neov[DescRieeo EzisTw�� u _weuv+�ro t�nueut uwex. � � ' CONSTRUC110N IENDING AGENCV � � (;:i_� !_-P:!�-, I horeby offirm that there 1s a construclion lending agenq �GNEDTHiS DAYOF 19_ � 4w the performanca of the work for whitb thia parmit is o'^'"'E°°R issued(Sec.3047.Civ.C.). �W�R3�� PWkE55 lender's Nama Lenders Addreu 1 certify�hat I hare read this applicatio�ond swte fAo��he above information is co�red-1 agree to comply wi�h ol�Counry ordinances ond Sta�e lows regulaAng Plumbing and Sewers, and hereby authorize repr entotives of rhis County to enrer upo �e above-mentia e propany fo�inspection purpows. 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