HomeMy WebLinkAboutNo Permit Number WORKERS'COMVENSATION DECIARATION .
I hereby affirm �ho� I hove a certificote of to�sen�to sel(
insure,nr a certificme of Workers'Compensalion Ina�rance,or 16A6d]D
a eertified copy thereof(Sec.3800,lab C.) �EB°a�REv.,�e,; APPL1CATtON F�t�R PERMtT �
Policy No. Company
❑Certified copy��ne�ebr+�������. SEWER • SEWAGE DISP05AL �
�Cenitied mpy is filed with the murtry building cmpecuoo � ' �UNTY OF LOS ANGElES --�� BUILDING AND SAFETY
dapar me r.
Dare 86 Appiitant Van Dieat & Son FOR APPi1CANT Tp F{tl IN CONNECTION DATA
CERTIFICAiE Of EXEMPTION FROM WORKERS' eunoi� ,
COMPENSATION INSURANCE �oorrtss �u ' = STATION ,�- o¢v�H i
(This xction need not ba completed if iha work involved by the i���ry Diamond Bar '��E aE��� EQ ��
permit is!w one 6undred dollors(5100)or less.) ,
I[ertify thal in the performonce ot fhe work for wfiich�his ��7 ry�a��T ��i��
CRO55 ST. Y. NR! >.l T�P.l.
permil is issued,I aha�l not employ ony person in any manner
so os to become subject to fhe Workers'Compensation Laws. ay�R T�le S;jI�{fOri C0. ����� v.c
N'�`u TRUNK f4RM11 NO. qOAD fERMIT Np.
pole Appliwnt nodiEsS
NOTICE TO-APPLtCANT: If, e4ter moking rhis Cer�ificaie of �iry TFi r�o '����T W^rv�° F�s�n�NT RE[OR0.INSTR NO. OATF
Exemption, you should 6ecome subject to the Warkers' i�qi
Compensotion prOr7sions of ihe Lobor code,yoo most forlhwith pe5crtivTiq.� �or NO. Nwv qt sr.wioeNinG
� iply wi1V�svth provisions or this permit sholl be deemed
�ked. eiocx TRAGT �62 � STATE FIVC C T
LICENSE�CONTRACTORS DECLARATfON r�p or°i°�s. �[p�.vT
I here6y affirm tha�1 am licensed under provisions ot Chapter �E a iot rrow on�ioT �
usc a �
9(commencing with Section 7000)of Dirision 3 af the eu5�- eu��o��5 Res cK.�¢cts �
ness and Professions Code,.and my kicense is in full force and
effect. cOnittaCrov �n } Cp'��EC71dV CMARGE fR
[icense Numbar 376a14 Lic.Closs C 2 appa[ss 7 " A�aner ,"�Y@. '- � RFiMBURs�r�NT r[E 0. '
ControctorVan Diest Dare � 4 8 atr �OxCO . '����"�q,�2 DISiRICENp. GROUP Mnv oer V i
TEL.NO � � i
❑1 om e:empt under5ec. of the LA.Co. l�ag r.q. E)8�I�' cuss ri 2 -��- ��i1ClU�, � I
Plumbing Code ond/or Sec. of the �� DESCRIPnON Of WORK rEe F��i -` - � !
�$E�W�ER CpNN[CfMG TO 1 00 DATE VALIDATION � �
8.$P,Code for�M tolfowing roason �� �
$PiIC TANK.SEEiAGE VIT pp V1
DO�e PITS AND/OF DRRINFlELD g� �., �
IqIJSE SEWER CONNECTING 10
- %tIVATE OISPOSAI SYSTE
5191WtW� Nf�1NECi AODITtONAL&OG OR �
OWNER-BUIIDER�ECL4RATION '�'or+�c To r�o�se scwea
ovEaiWw SFEaACE wt OkaruiElo
1 hareby affirm iFrot I am exempt from tha CoNractor's license E%iN.,CFSSV004 DRYWELI,MANMOtE
law for the following rceson(Sacion 7031.5,Buisn@55 ar�Pro- P1iER.REPAIa pR ABANDON HOUSE
fesSiOns Code): SEWER OR WSPOSAL 51'STEM
��1,as awner Of the property,or my employees with woges os �'� =' ����^
�heir wle compensation,will do the work and Ihe shuN�re
��� � s iij
is not iniended or offered for sala(Section 704.1,Buai�em
and Profeuions Code). OWNER�S permit S 'JQ 0
❑I,as owner of the properry,am ezclusively mnvad�ng with AUTHORIZATION TOTAL FEE 2 � � � ` ��'
licansed contracron ro coos+ruct the proieci(Sec»on�044, I HAVE A7 MIS DATE A CONTRACT WIiH THE MEREIN NAMED CONTYACSpF i0 . , � , �.,x
Bu5in655 Gnd Proleuions CoJe}. CONNECf THE nBOVE OESCRIBED E%ISTING DWEll1NG TO iHE PUBL�C SEwER ` " '''
CONSTRUCTION IENDING AGENCY � p , ;��, �
i hereby aHirm that Ihere�s o constructioo lending agency SIGNEbTH15 DAVOF t9_ �"' � ` '� - 'I
for the performance of the work for which this permit is o�as�� I
iuued(Set.3W7,Civ.C.). ''
R07RE5$
tander's Pbme �'
Lender's Address '
1 certify thpt�have read�his application and stote that Ihe ,
above informo�ion ia correct.1 agree�o comply with oll CouNy
wd�nances ond State lows regulating Plumbing and Sewers,
ond here6y authorize representatives of ihis Counfy to enler
u the ahove-manf�o ed properiy for inapection purposes�. Q
.�Un A�jk'`� ����'6//�
ignat�re of Ver iNee Dote � SEE pEVERfE FW FxPlANA70RY LANGIIAG[
�.. w � �
.., o= ws -. .
� „,:: �^ c a�.o E`�• R R�'� c " s „ 1
'n v.:V 0 .'�.. oi•C '� 4 C.tl X �� c'�t p y'� � � � ' '
v
z �j ` � . a t o�c t �. `
�� .�x", � �s E a y E
c^ a; �c � � ; �3 w v � g 1
a.en � .: s C t� s.� J �c n
td�'�.. O '�S�L � �- °'`^C = � a' r-,u'.� �:" i.. ' 1 �
� � �... C C C b � � .+ �.� G � = C.3 G ' 1 .
CO O'Ct ~ �v oVi"dG C4 u C 'O � �. �'C''C5 !
O ;, u y E V; C�• C � 'G C'� C f d 3 � �I
E"' y� °'e �'�,.K J�yo-. � •o c ; .�.r c = .c �, I
d �cr. Q o _ .�.,,,... � o� o °' '3 �U �.o � u o x > v:
�, o,m o 3 o s �.� y�� m=, a c d c o� � �� 1
Q' � �'� F �c , �'�. ^ � � y� O � s..,;�.�,� ;J� y �
U y� � � a �v'��.�;.,.''c c �c „3��� �� � '.�.. ' 'I .
y�.a «. ��. o, -' .n r a�C c ' . m �'�,C .0 ! 1
� q•r r � .`'v. y y 4 O.r � i ^ = r►
Cl y' a R � o'�,c,.� ��= " � �� � :. c.� � � .+ �
�
W � .S.o.0 � o«V��r oa ^ �� �. �='� c�°�M`' .-. � � � t.
Q =w = C�C � .:,C•"' C O � C'„ u aj C�.u O y " V y U � �
- � � �� � �Q° a�� �a� 3NC� O.v.kn 6y a+ ���+f .°�+ 3 '
J w s '^�.« =..0 C S � O p G�C N Y L" � �,.�z� m`�,O .�,,. rr� � n C •
� �wC ` C �'' �' 3 Oy � .�G'� �C�+�C °� p"3 y � � d � � ` 1 ' '
� �
iia �,�C' R � � �'�'�_,,:��.± � �r" � j y�.C `� � � . , �
�' �'i.1 � e tl w � ��.' �V�cj',��,7 i:G`'� '
y y � i � c'� m n a y r, ` ` '
O ar `n »' L u V � yv„ C 3,� I, 1 �1
L y. � 4 � y e[ `� �
�,�,a...�.;a ' ,
Y+= .� � n. d�' 1
r�m L ' � ' . � �
S �
i
. � � i�
� � � 1 i
I . �
1 ��
� � ' '
� , �� � i
� � '�, • !+ '�, ' ., `_ ,l
, � , � , � i
1 `, � � . !, � � ``�, � ,., � �; , � � 1
N � ' 1' ,,`� � � � ' '
� . `, 1� : �_ � � I I, �. ' � '' � ��, '
o � � �
N � ' ! �' � �' -' " 1! ' �� � �i �� � ''�
;� , i , ; .
�i ��' �� ' �� � � . � � • � � �l� ��1 � �
W � I 1 �. ' �1 �� �i �� i � �
Z ' ,r ' ,} !` '1 'I `1 ,;1 `,,+ ' ', ` l ' ' ,
' � 4 } i P
``� � 1' '� y,i �'� � �` _ �� ,, '
`� � � ; ; ' �
;.y , 1 i ` ' ' 1
' 1' R ' t � �
. ' . � ! '' ',1
, � i '1
�1 �
t ' . . ��' ' � � � `', '1
W '' '
< �Q 1 'I �
. ` � �` , 1�
s �:
� o �` 1 i �
�
r� t 1 � ' � 1
�. __ - - �� , ; `;; �, � ,
.� _ - � �. ':; �
� � _ _- � . � `!, � i
_- � ' �
� ❑ .� � ,
; � '
11 � � � U� , . �
1 ' . 3' L:N I i 1 Y�
`� � d W✓' dJ� ���) ,
O
��' a.y �u. LL�.1 7 j ^
O ° U� 1✓'1 or�i+� o.p �'rn Cl
e L7 p�n iJ z ✓ �
I�'`�+ n� o ,u'
iC�� � QO 'z�a� Q, °`� i�� '�
6 ,'� `"Z uv a W 3 ;�m `q y,
x 1�? --a � �� u 4 �,,,.
' ; p� �4 —�
z j��, �'"'-
:�'�� r-'