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HomeMy WebLinkAboutNo Permit Number (112) WORKERS'COMPENSATION DECLARATIpN � � I hereby affirm �hot I hove a cenificote of consent to self _ � insure,or a certificote of Workers'Compensotion Inwronce,w �anbazo o cerlilied copy thereof(Sec.3800,La6 C.) �EBaB�RE°„83, APPLICATi4N FOR PERMiT . Polity No- Compony . . . SEWER - SEWAGE DISPOSAL ' ❑Cerlified copy is hareby i�rnished. �[e�r�f�ed�opy�e f�1ed with rhe counry building�nsPan+o� 3� GOUNTY OF l4S ANGELES�7-� BUttDiNG AND SAFETY deponmen�. . . . - p,,, 86 Applicani Van Diest & San WR APALICANT TO tiLl iN O CTION DATA CERTIFICATE Of ExFJ�AFTION FROM WORKERS' eunoirac COMPENSATION WSURAf+iCE ADDRE55 20933 .^.�"'a. rtt33.I R72ri I�l. sutm�+ �H �This section need nor be completed if�he work involved by tlre ia�iTr Diamond Bar �NlfOIE GEiFpFNCF iovrte permN.is for ona hundred dollars(5100}or leas.) ��ES� Tvr�a caw+[a �Fr�cTH rcpn� � t cerliSy rhot in�he parformonce of tha work fw which�bis crto555i. r. tuRa �T�P��� permi�is issued,1 shall not employ ony perwn in any manner p,�. w as ro 6ecome subject�o tfie Workers'Campansation Laws. pY,r�R 1$B 'r�lOZyOT1 (�i0� [o tMv r+o. �k TYUNK PERMIT NO. IIOAD PEGMIi NO Date A��ICOM A�pf� AFfIDAVIT WAIVEY FASE/AENT RFCORD MSTR.t�. MTf NOTICE TO APPIICANT: It, after moking ihis Certificate of �in. �rao. Exsmption, you should become subject to the Werked «i � I Compenmtion plovisions of the Labor tode,yoo must forihwilh p[$�RIRIdJ ��T�� NWV OR 51.WIDENING � �ply with xutb provisions or this permit shntl 6e deamed / �ked. � �oa TRhCi � �C 2 STAfE ENCI20AC T No.a�ocs ffR'"n LICENSED CONT&ACTORS DECIARATION s�:e or ior now oN ioT � a II hereby aHirm thot�am licensed under provisions of Chopter �� i, � ,9(commencing wilh Sectio�7000)of D:vision 3 of Ihe 8usi- eunD��es ^o wMiGES �nex and Profess�ons Code,and my�icense is in fuil farce and �effetl. corrranaaR V� Diest � 5on CONNFCTIpNCHAqGEiFE � : License Number 376814 Lic.Glass C 2 Rppa�ss -X REiMBl1R5EMFNi F� �, � � v3T1 vL08t &. � `1 4 4 s6 . � DISTYKTPIO. P r+,�s v� er �� � Contrxror d'a�e aTr ldorCO hi.r.w. 7 — 2 � � O ; �.� 3q 81q �� � � a ���- " � I ❑!am eaempt under Sec. oi rhe l.A.Co. i���Fp anss NO. DESCRIPlION OF WOWK FEE � 1 Plumbing Code ond/or Sec. of the Fiwu O � i "a��'''�a CON"E�""�tO 17 00 w'E VAtIDATION v 6.8 P.Code for�ha following reoeon vUBL�C SEWER p � SE 1 TANN,$EEPAGE GIi pR w~ O. ( �Ole 7�75wN�/pqpqAlNF�EID R� N � iKK15E SEWER CONNKTINC TO �Y � VR�VATE DI /� Y $i9nCture CONNECi AODIiqNAt BIW.OF � OWNER-BUILDER DECtARAT10N WIX+K TO NWSE SEWER OVFfIfIOW SEE9AGE➢iT OPAINF�flO 1 I hareby offirm thot I am exempt from iha Commc�or'3 tfcense exm�_�ssooa oxrwEu.+u�+Ma[ s Law for the folfowing reosan�Secton 7031.5,Boisness and Pro- ��R�oR��i��M�s¢ � fessiona Code): n I,as awnar of fFe property,or my employees with woges as ( Iheir sofe companaotion,wilt do ihe wwk o�tha structure ' . � �} ��7��`� � is not intended w offered for eole(Secrio�70d4,Bosiness permit s �� 5� '' cnd Rofiessions Cede1. OWNER�S i�= �• •I �' ❑!,as awner of the property,am excl�sively coniracting with AVTI'�ORIZA�'ION TOTAL FEE 7 + �,.. �,„ licensad controc�ors to comtruct the projed(Section 7p44, i Hav[A7 TMIS DATE A CONi4ACT WI7H iM HEREiN NAMED COMRACTOR TO " ' BySII1BSi��1(I PfOfBSS�Of15 COGB�. COrIDkCT hiE ABOVF DESCRIB[p EXI$TIPK'i DWELLING 10 TNE iU&IC SE'MER • T�, ; ,_ CONSTRUCiION LENOING AGENCV � ` ��" ' I hereby affirm thot there is o cvnshucfion lending ogancy SIGNEOiHIS DAYOF �9_ V for the performance of �he work for which this permi� is �RS�� � `�.�I '�_�f' � iss�ed(Sec.3097,Civ.C.). MDRE55 � lender's Name Le�der'�Address I certify that I have reod this application and state that the ebove information is corrett.I ogree to comply with all County ordinonces ond$tote lows regulming Plumbi�g ond Sewers, ' and hereby authorize representotives of this County to enter � up he Obove-menti ed prOperry fot inspection purposes. 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