HomeMy WebLinkAboutNo Permit Number (152)WORKERS' 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. 3800, Lab C.)
Policy No. Company
❑ Certified copy is hereby furnished.
Certified 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 fo 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 3.76914 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. 8 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• (T`uail Run DT•
stAr10N DEPTH
TY
F
MANHOLE REFERENCE
T
sr.
TYPE OF CONNECTLENGTH FROM
Y CURB P TO P.L.
OWNER Th ''T
P.c. No
co. tMP. No.
MARL
ADDRESS
TRUNK PERMIT NO. ROAD PERMIT NO.
AFFIDAVIT WAIVER EASEMENT RECORD. INS7A NO DAIS
CITY TEL. NO.
LEGAL r
DEscRIPTKNI LOT NO.
+
MWY. OR ST WIDENING
BLOCK TRACT
STA NT
ND OF B1W5
PER
SIZE OF LOT NOW Ory LOT
E12
USE OFtTTT,,,�
Rs.
/ • %�
BUILDINGS
CHARGES
CONTRACTOR Diest rD'.' Son
CONNECTION CHARGE FEE
pVan
1494 Hamer Ave. A
ADDRESS yT
REIMBURSEMENT FEE
CITY TEL NO.
DISTRICT NO. GAWP MAP SSEDSTABY
LICEENSE NO. 6B t A CLASS y ,42
SK PG
/ a
NG DESCRIPTION OF WORK FEE
SEWERCONNECTING TO
FINAL
DATE
P�1uK 17-6
J��{/_ VALIDATION
SEPTIC TANK, SEEPAGE %T
PIT$ AND/OR DRAINFIELD
FINAL / N
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM
BY /
CONNECT
CT BLDG. OR
WORK HOUSE SEWER
HOUSE SEWER
OVERFLOW SEEPAGE %T. DRAINFIELD
EXTN , CE55POOL, DRYWELL, MANHOLE
ALTER, REPAIR OR ABANDON HOUSE
SEWER OR DISPO&AE WSTEM
OWNER'S Permit 10.
# • • 'I
AUTHORIZATION TOTAL FEE 27.190
IFAVT AI A CONTRACT WITH THE HEWN NAMED CONTRACTOR TO
CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER,
SIGNED THIS DAY OF 19_
OWNER OR
OWNERS AGENT
ADDRESS
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