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.
Yt_ �
Siflno�uro of Per fiHee Dote ffE REVERSE fOY EXrIANATORY IANGUAGE
�
r�- � � % � • ,
y x -
o v, w -
'^ ,r '. d
" .w �.v �
`ti.r; C �� 'a 'u '`r,,',r, � � '� � 1 M .
�. ����. � d � 3` � .Y y' �' .x�•C L� y ,� .-
.�:C e= m o o� c..�a �. c c„� L�; c .
� '� `n � 'C u O E C'z'.. � : T� E '' � � f .
'✓M =w i C d�z Yt i i 'J Y y �"S�Y. � � � , .
v O � � S. C �` N r.=.O t% � ��.�i��.. C ` �. .
�� ¢ � v c = �� C � � 'r!- � '. � k.o"3 t\ ; �1
Z G � :S °� wU'i� �ap T�. ^ •. = w.0 � 1 1
� O a V�^O � S� O.��'.•�C „�G 3'CC" 'L'' p C .� Q , . ,
� y�; G C V.o,y-..� Z. a' G C '.!a uV r,.:. CI C y C � ..� . , .
� �,n,v ,ty o i v.z e� �„�, n� s .. �s� c! y„
� � a � �
� C Q'� �� � � ¢ • c �.� c.�,,, ;r ��? �`c � ,
ri .�i. W = ' � =J =�='c w'.n �, i. ��`...-,r,� � °i 'C ��� . � .
� .. 0. S Y
y V �n L .r y'a... d''4 y„L Y � �
v �,�+'eC -' p." ..C. 'nu, � . V.�p:.. G C C w C.6 � Y 1 �
G � y';, "`�- 'G-�,�=..o��� sc„ � ` t'' ' ==_ .�G `: � � -
�f . v ; » o � �'^ Q •• " y o =".� : �.�i cc t '� t'
� •C �
� y =J i i..C a: �v.� � �p . K^•' m„�C� Y` (� � 0! . .
�/]� � � O i w O� "G r C N y .4'L'' S . 'V G
1/� r w O p d i .�. a � 6 m u�3 G 'n'cCn 4.,y� y G.6 y � Cd �` .. , � `
= ' G ''
,. d... � . �, a� �:_ „ G . ,;�`�.�� � y
� y: -� � _�c r � e c a,a y �,�.d �'� � c Cy p � ,
, 1+� �w` � i v. �;'i O �� q �G �. v,� v"+�y - ,
� �� � � ,
W � a=�V.`'c�'c�p v�... � �V������ o.
a,,� d e C��c3 V o c•� o� ...C v V�..��'+ C. 1 ,
7' H fn i a �, C_'.''-. � � 't' � y`� ' t
� d � N i '� y u "^ Nl 4 ��^-'� �
O y ,G,� �b.o.�aa " , �� , �
r u � `, ,- 'a� ' , . . t
a� , ` .
1 ! �
� � : . � �
, � " ` ' �
` � �� i . �� � � �, �
` , ', 1 ' ` ' , `` ,� !
`; � 1 " � � `. ', � ' r . . �
; . ., ;
, ., ; �� �, , , � . � �, �
,, ' �' i ' �' , � } ` '
. y ` � � � ` ' � 1 1
r i ti �� �` ; , '+,Y 1 1 ,1 'j `, 1
� t' � �. � .� # 4 �' �� � � , '� � 1 t �
G ; � �� �� '� � �� � � 1, ',, . � ,, � t �,
� ' . 4 ` �' ;�,� ' ' � ;�� Y 1
� �� 1 � ; � � ' ,,
. 1 ; � , ,, ; � ,�
' '� � �.
, ' � ' s ,
' ' �
t , I, '� t; t: . ,, '� �,
� � �
� � , '
� �
� � �. . ,
. . ,
.. . . W '' t ,, �
�
',u 1 , Z 1 � �
,� ; � ' � , � "o�'� t 1 1
a ,
N ,'� � � 1
.++ � W • �
�7 ; ';t �
"s t� �i -��� Z
_ 1 � ,, ! '
� � '� t � i ,. i , i
� '�.��� �' - � �
E� _�� �,.
��� ' � `� ."1 �
�,� � s � �
, �r� , � , �
'', � W �.�=�. �>�U�s
; '� 3 •,�s
��/1 , : �, 1a?� a:n1YYi . .
' �J 1� i, �-. , u-; � '
,`d `•a ,'�3 1,.=� G?�'�E,
�7 �.� ,1 t`�,�? �.•;.���°�. �, _,�-
'��° '� G�I�Q ° 4�� •, � _._---
I� tlJt P� Y� ,W W :S 4� . .
,� aO,Y� � a�� ��j;. ,. .r
. 1 a U U 7'`�n � u�r �.3,c�.-.t�?��;1'�
_ ' P .n G _'
S.. 2��4 U .6✓'
Z O� _`�.
V
,..-�'_
�