HomeMy WebLinkAboutNo Permit Number (112) WORKERS'COMPENSATION OECIARATION !
I hereby offirm �hat 1 hove o certificate of coosenl to self (
insura,w a certi(ica�e of Workers'Campenwtion)nswonce,or �����
O tertified[opy thereof(Se[.3800,Lob C.J �E 80B�pEv„�� qpp��CATtON FOR PERMiT �
Policy No Compony � C
❑Csrtified copy is hereby furnished. SGWER - SEWAGE�DISPO&At
�Certified copy is fibd w�eh ehe caunry liuilding inapeoion � OUNTY OF LOS ANGEIE��' BUILDING ANO SAfEfY
depar�ment. � �
�,g 86 qPplicom Yan Diest & Son ipR APPtICANT TO FILL IN ONNECTION DATA
CERTIFICAOMPEN ATIO�NSU AIJCE RKERS' ,pp�Eu 2 �' ^u27.1 Dr•
STAiIQN D[PIH
(Th�s secrio�need nor be comple�ed'rf the work�nvolved by rhe i«Aim I}iamond Bar M�NMOIE QfiFIlEHCF UPPER
perm��is fw one hundred dollors(;106)w less.{ ''
I cerri thar in rhe r+E^Resr . nvc a cor�ctpra �rN Fxon+ '
fy prformonce of ibe work fa wbich�his cRpSssr. v. w�+e v.i M.i.rov.�.
pgrmit is issued,i shali nbt employ ony person in any monner
w ci to become subject to iha Workers'Compensation lows. ow�a T�'1C ��iIILj{�jD ri C0. �p iMo.r�o. ba r o.
Mnii
Dote^�Applicont ' �ODRE55 TRUNK FEFMIT NO.� Rp.�p PERMR NO.
N6FICE TO APPLICANT: If, aher making �his Cerriticate of crtr TE�NO MKIW�VIT wuv[e [as[n�NT qFWR�.INSTq NO. OATF
Exemp�iort, yov should become subjeU to the Workers' ��u
Compensation previsions pf the Labor code,yo�mpst forthwiih �yR�m� �ruo
nply with such provisions or Ihis parmi�shall ba deemed �oasr wioeHiric
� �kad. aiocK TRA�T 43�62 II SiATEENCfiOACHMENi
' ` .LtCEMSEb CY)NLRAGiIIRS OECIARAT[ON�... r+o ar�a�s. � ra.
SIZE OF LOt Npw pN�pr
1 hereby affirm rhat 1 om licensed under p�oaisions of Chapter �a
9(commencing wirh Section 7p00)of Diviaion 3 0(the Busi- Bwmu�S �e:. o���s
neu and Professions Code,and my license is in full force and �
effKt. ^ ^ �pNTS�CTOR .� i� .Q. n CONNECiqN CMARGE iff
licenm Numbec 376814 Lic.Class v �G ��� � � .�. ' ' P � REiMBURS(MENT FEE � ,
� tr2�_@— :iV6. a� ri p, !
Contractor Van T3i�^.. Da�a d�fci� c�rv t�OZ'CO rei.Ho. 7TJ��7nt�2 oisimaruo. crtour tiuv sseoir � � j
/� BK PGJ
❑1 om exempt under See, of�he L.A.Co. ��N��,p z �a n �wu p+v � /1 rl.�_�+' O .
N� OESCRIPTIONOFWpRK IfE �o�t0�
Plumb�ngCodeand/or5ec. oHhe �pU5E5EWFRCONNECTIfJ�TO DATE` �{ VALIDATION �
B.&P.Cade 4or the fdlowing reason PU&1C�R �"�p p,
SEPTIC TM➢f.SFEiACE PIT OK N
PiTS ANO/OG DRAIn�lELO F�NA� ^� '
�O+e NOUSE SEWER GONNECTING TO BY
YRIVarE olSPOSAL SVSTE �
S�gnmure cnru�cr anoir:au�azpc oa �
OWNER-BUVIDER DECIARATION `N°R"To�+ous�s�w�°
OYEHFIOW SEE7AGE RT,ORAINFIEID
1 heroby offerm thot I om exempt from the Contracror's License [xrv,cessvooe,ocvwtu,nue�Hae
Law for the following reason(Sacron 7031.5,Buisness and Pw- uTea.a[raic o�t ne��moN rrou5e
fB5S�0�3 Cof�b�: SEWER OR D�SPOSM SYSTEM
. �I,os owner of the property,or my employees wirh wages as � � `_ • �
{ their sole rompenwrion,witl do�he work and the strucfu�e
` is 1wi inlended w oHered fof acle(SeCtion 704�,BWiness - . . .. -..�F'�F�.-"o-7 :'.
and Professione Code). OWNER'S Permi! f �
❑I,as owner of�he property,am exclusivety comracting w��h AUTHORIZATION FOiAI FEE '� � �^""
4icensed controcrora�o consrruu iha projec�(Secrion 7044, i��A�i„�s oA.e n mraraAtt wrtN�'+c Hcaew w.�o caara�nere To e s . �
Business ar�d Prafessions Code). corrr�eci rHe neov[DescRieeo ExisTw�oweuv+�ro t�nueuc uwex. � � '
CONSTRUC110N IENDING AGENCV � � (;:i_� !_—P�!�-,
I horeby offirm that there 1s a construclion lending agenq �GNE�THiS DAYOf 79_ �
4or the performanca of the work for whitb thia parmit is o'^'"'E°°R
issued(Sec.3047.Civ.C.). �W�R3��
PWkE55
lendar's Name
Lenders Addreu
1 certify�hai I have read this applicati0�ond swte fAo�the
above information is co�red-1 agree to comply wi�h ol�Counry
ordinonces ond Sta�e lows regula��ng Plumbing and Sewers,
and hereby authorize rapr entotives of rhis County to enrer
upo �a above-mentia e propany fo�inspection purposrs.
SigrwN�eofVermi ee � Date � iEE�Ev46iFORE%1{ANATOtYIAMfi1lAGfi
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