HomeMy WebLinkAboutNo Permit NumberWORKERS' COMPENSATION DECLARATION
I hereby affirm that I hove o certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, or
a certified copy thereof (Sec. 38OQ Lob C.)
Policy No. Company
.,k❑13f,.Certified copy is hereby furnished.
1sCerlified copy is filed with the county building inspection
department.
Date B6 Applicant Van Dieat & Son
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the work involved by the
permit is far one hundred dollars ($100) or less.)
1 certify that in the performance of the work far which this
permit is issued, 1 shall not employ any person in any manner
so as 10 become subject to the Workers' Compensation Laws.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor code, you must forthwith
4` •ly with such provisions or this permit sholl be deemed
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Coder and my license is in full force and
effect.
License Number 3.76814 Lit. Class 2
Contractor Van DieSt Date 4/4/86
❑ I am exempt under Sec. of the L.A. Co.
Plumbing Code and/or Sec. of the
B. & P. Code for the following reason
Signature
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Low for the following reason (Secion 7031.5, Buisness and Pro.
fessions Code):
as owner of the properly, or my employees with wages as
eir sole compensation, will do the work and the structure
I. not intended or offered for sale (Section 7044, Business
and Professions Code).
❑I, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Section 7044,
Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued (Sec. 3097, Civ. C.).
Lender's Nome
Lender's Address
I certify that 1 have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State lows regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upo a above -me i I ed properly for inspection purposes.
5 noturo of Per ilea Date
76A6J2D
CE 808 [REV. 11871 APPLICATION FOR PERMIT
/SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES/,-,, /-#UILDING AND SAFETY
FOR APPLICANT TO FILL IN
ONNECTION DATA
20930 E• �`uail Run DT.
st-ION DEPTH
ALITY
fA
MANHOLE REFERENCE
REST
St.
TYPE OF CONNECTIONLENGTHPROMOSS
CURB P TO P.L.
t�OWNERTtl 1'T
CANOrADDRESS
TRUNK PERMIT NO. ROAD PERMIT NO.
AFFIDAVIT WAIVER EASEMENT RECORD. INSTR NO DATE
TEL. NO.
L r
TNN! LOT NO.+MWY.OR
ST WIDENING
TRACT
STAVNC HENT
PEA
LOT NOW ON LOT
USE OFtTTT,,,�
Rs.
J/E
/ • 7PJ
BUILDINGS
CHARGES
CONTRACTOR Van Diest & Son
CONNECTION CHARGE FEE
1494 Hamer Ave. A
ADDRESS yT
REWBUMWNT PEE
CITY TEL NO.
DISTRICT NO. GAWP MAP SW BY
LICEENSE NO. 6B t A CLASS y ,42
SK PG
/ a
NO DESCRIPTION OF WORK FEE
PNSEWERCONECTINO TO
FINAL
DATE
PK
J��{/_ VALIDATION
SEPTIC TANK, SEEPAGE NT OR
2�
PITS AND/OR DRAINFIELD
FINAL / h'
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM
BY /
CONNECT
CT BLDG. OR
WORK HOUSE SEWER
HOUSE SEWER
OVERFLOW SEEPAGE PIT. DRAINFIELO
EXTN , CESSPOOL, DRYWELL, MANHOLE
ALTER, REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL WSTEM
OWNER'S Permit 10.
# • 'I
AUTHORIZATION TOTAL FEE 27.190
L—ADD!IS" I— UAA A CONTRACT WITH THE HEWN NAMED CONTRACTOR TOTHE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
HIS DAY OF 19GENT
SEE REVERSE FGII EXPLANATORY LANGUAGE
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