HomeMy WebLinkAboutNo Permit Number (134) 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
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