HomeMy WebLinkAboutNo Permit Number WORKERS'COMPENSATION DECLARATIpN � �
I hareby affirm �hot I hove a cehificote of conient to self _ �
insure,or a certificote of Worken`Compensotion Insvronca,w �anbazo
o cerlilied copy thereof(Sec.3800,La6 C.) �EBaB�RE°„83, APPLICATi4N FOR PERMiT .
Polity No- Company . . . SEWER - SEWAGE DISPOSAL '
❑Cerlified copy is hareby i�rnished.
�[e�r�fied�opy�e f�1ed with rhe counry building�nsPan+o� 3� GOUNTY OF l4S ANGELES��-� BUttDiNG AND SAFETY
deponmen�. . . . -
p,,, 86 Applicanf Van piest & Son WR APALICANT TO tiLl iN O CTION DATA
CERTIFICATE Of E%EMFTION FROM WORKERS' ppo� 20 „ ��Z �� �� surmr+ �H
COMPENSATION INSURAf+iCE 933 =�
�This section need nor be completed if�he work involved by t1re ia�iTr •DS.amond Bar �Nl10lE GEiFpFNCF iov+Ee
permN.is for ona hundred dollars(5100}or leas.) ��ES� rvr�a caw+[a �r�cTH rcpN, �
t cerliSy thot in�he par�ormonce of tha work fw which ibis crto555i. r. tURa �T�P���
permi�is issued,1 shall not employ ony person in any manner p,�.
w as to 6ecome subjea�o the Workers'Gampansation Laws. py,r�R 11'12 'r�lOLyOT1 (�i0� [o uwv r+o.
�k TYUNK PERMIT NO. IIOAD PEGMIi NO
Date A��iCOM A�pf� AFfIDAVIT WAIVEY Fh4E/AENT RFCORD MSTR.t�. MTf
NOTICE TO APPIICANT: It, after moking ihis Certificate of �in. �rao.
fxsmption, you should become subject to the Werkeri «i �
I Compenmtion plovisions of the Labor tode,yoo most forihwilh p[$�RIRIdJ ��T�� NWV OR 51.WIDENING
j �ply with xucb provisions or this permit shntl 6e deamed /
s �ked. - � ... �oa TRhCi � �C 2 STAfE ENCI20AC T
no.a�ocs `�RiNQ
�' LICENSED CONT&ACFORS DECIARATION s�ie or cor now orv�oT � '�
II hereby aHirm thot�am licensed under provisions of Chopter ��.y i, �
,9(commencing wi�h Sedio�7000)of D:vision 3 of�he 8usi- euno+Ncs �e wnxc65
�nex and Profess�ons Code,and my�icense is in fuil farce and
�effetl. corrrrss.aoR V� Diest � Son CONNFCTIpNCHAqGEiFE �
: License Number 376814 Lic Glass C � Rpp�ss -'c REiMBl1R5EMFNi F� �, �
Van Aiest & � n 4 4 s6 . � _ o�s,��� P ^^� o� BY � i
Comrxror 0'a�e aTr NOYCO ht.r.w. 7 — 2p� � � O
I ❑!nm eaempt under Sec. oi fha L.A.Co. ����.p 37 814 anss � `t'- �' ���� O �
I alumbing Code ondior Sec. of rhe � DESCRIPIION OF WOitl( �e F�� �
� `au�s�v,�coNr�cnnc ro �7 pp wre VAtIDATION v
6.8 P.Code for�ha following reoeon vUBLiC SEWER p �
SE 1 TANN$EE�/.GE GiT OR w~ a. (
�Ole 7�i5wN�/pqpqAlNF�EID R� N �
iKK15E SEWER CONNKTINC TO �Y �
VR�VATE DI A Y
$i9nCture CONNECi AODIiqNAt BIW.OF �
OWNER-BUILDER DECtARAT10N WCN+K TO NWSE SEWER
OVFGfIOW SEEYAGE➢iT OPAINf�fIU i
i hareby offirm thot I am exempt from iha Commc�or'3 License exTM_�ssvoa oxvwEu,rM.wMa[ s
Law for the folfowing reosan�Secton 7031.5,Boisness and Pro- ��R�oR��i��M�s¢ �
fessions Code):
n I,as awnar of the property,or my employees with wages as
( Iheir soie compa�notion,wilt do ihe work o�tha shucture ' . . �} /��,`�
� is noi intended M O�fereJ for lole(Sectio�7044,Bosiness Permit s �� 5� ''
cnd Rofiessions Code1. OWNER�S i�= �+ • I �'
❑1,as owne�of the property,am excl�sively cont�acting wilh Al1TF�ORIZATION TOTAL FEE 7 , �,.. �_„
IICBf�58d GOt1f(OC�OfS 10 CO�SflUC��f1G P�O�lCI'SEf110I1 7O4A, i MAVF A7 THIS DATE A CONiRAR WI7H illE HERE�N NAMEO COMRACTOR TO " "
By5111BSi��1(I PfOfBSS�Of15 COGB�. COrIDkCT hiE ABOVF DESCRIB[p EXI$TIt�K'i DWELLING TO TNE VU&IC SEWER • �, ; ,_
CONSTRUCiION LENDING AGENCY - ` � ��"��
I hereby affirm thot there is o conshucfion lending ogancy SIGNEOiHIS DAYOF �9, V {
for the performance of �he work for w6ich this permit is �RS�AGENI � �'� ' ~'J�� F
iss�ed(Sec 3097,Civ.C.). wpRE55 �
le�er's Name
Le�der'�Address
I certify that I have read this application and state that the
ebove information is corrett.I ogree to comply with all Gounty
ordinonces and$tote laws regulming Plumbi�g ond Sewers,
' and hereby authorize representotives of this County to enter
� up he Obove-menti ed pOperry for inspection purposes.
k` �
Siflno�uro of Per fiHee Dote fFE REVERSE fOY EXIIANATORY IANGUAGE
r �
� � � . '
y,� . .
4 -
M S 4 � V V � \ ' .
.,'w G •� 3 £��� c.`^ . � �
- tp ,o x u 'i .
r p.�+ O �� i y ��.O L.n., p .
` �,�n .` ��.. L 6 � C C.C,'6 �'. = C" � �
' u.v�u C= .�C O O C � C'�.. O i S y y `e. � ,
'� ssdpdr`�. s K � ,"., � v w �'`��^ � .
r in S .. y« � �. a �o S��s c � � ,n C � ��� \
�o o •o E .. � \ " \
r1/ Y O V E V C V� o 's' CS �O �` a� v' �` � c� � 1 L � _ . ' .
�/� Y' O 'O . ,�„ q'O�w'.. �. C i C G C C � .h , 0
� J•�u ��. o. z�67 c rc.c.e �3 �C� 4� � u o c y � . .
� v C
E t'�'..' � � m`�''o�s c s� �' r G o c i �`'��' �c, �y�r. �" .
�`r"' G' uC y . b4� C C �f',,, '". G T',S �C�7 .:R 6/ � .
d c�; �.�,.�o„c 5��`^°a L ,�. �=,.,�„��� s 1'' .,.i \ ` .
� �\
�,,,� ,,,, co t ' ,,, C ;.n� 6 y � _.� « '� '� L \ � .
y'2. .~y..'�' G... Y n'^'" .' V'O "" �'C i, G'C t'/
V � d � � - L' ,�n;,� '� s^ tC � � C. �: =s a� �,y y .
C, �3�y��� �� y� c �`�� ° �.^� �r,�� � U �� � .
'�^ i v ... o �-�.a J�^c ... ��, G o - °' '' �,.�. o s- 6- y � /CO�. �" .. \
�, F. ... � �.y ��u d M-• ���Cc.. �r.,... y G" � yr, � .
'a ,,',�,. r p c.� .. d � �3 �. � ��
0 ♦ i� yv�C�m �C cay 4G° �s�r``"'' c��, �y p .
`� i� '� O.•" �� 3`�^�d= o> � t+'r e`� C' °'C,.:� i�„ r \
�rr j � V ,�� i v. ' �'"„�d � �'�„y'A ?�? � v-t� � � �,, �
W `� a = �, �'^a'--� c-- g � "� � o> .. � c,'"�;�' . � \ 1
t d C .�S Y o b'� ?'"�C°� Vi..�t'
'Z, s.✓ v, B �u � C.'.: � L�L �y � � \ \
� �i N � i.,�".•� y u G �Q
1 \ \
� y u� av�o.r..3".a �, .
r u � i �' n� \ � .
a�
` \ ' ',
� , � , , �
' �, � � � �. `. \ . �
� � :,. ��, ` �
� .\ � � �
� � ,i',, `\ '`� ' . \. ` \ . '`., r, `
\ \ \\ ` '
; i \ � � � � � � � ; \
� `� �\ � �� _ ` �� � �\ '� . �\ �
y ' � , ,' � \ � �,�• � V � .� � ��
� \ . � � '` `` � `\�� s ` , i'� ,i \ � \
� v � . , � , �
� �� � �� � � r � . � � �� ��, . , �, � . .
G � � , \ \
� \' \ • � i\ \ \ \ ,� s
\ y � \ � ,\ \ � i t \.
. � �. \1 � � �
\ \ � ,\
V �' � ��. 4 • \
� � �, �� '�\ ` '� � � �
\ \
`, \ \ �
,\ ` , + �
. y \ \ l
r �.
. Z �\ � �
� \ 1
\;� \ ' \� ' . �� \\ `
� � '•\ \ � o- . \
� N
�
� , �
�'t, ,� �•\ y � !
W �� �r � � �
L \`11 � � , ' '� ,
���,� � , \ '
,
�,. • ,,— `
\ `
<, ,�.,�. \ .
F.,� . ,�
y�:�_ � c� �,
� ` S 0� �p '
� � +'��'_ n>1%s ' . . .
'� \ � 1 3 1 O;n '\ i', . ,
� �. > \�.Ys a;n s.
`� , i \'°g " \',,�n':,'\;�(_-� /
,`�r � � ` ` � &,i�`�' • /�/
,,70 y c _i �, "."�, .,
� �
. �a J; e�\✓y� �Q�\n+\' ,jiSy µ
�\G Ji V 1`�-O T> W� ✓��� ��;:M1
�4 u �,o N �� �a
. \ s Zq'� c'+'4 U --� �
Tiy Vm'� ^���