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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'�.. 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