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HomeMy WebLinkAboutNo Permit Number WORNERS'COMPENSATION DECLARATION I hereby affirm �hat 1 hove a cartificate of coneene to aeif � inaure,w a certificate of Workars'Compensofion Insorance,or 16A64D a certifiad copy ehereof(Sec.3800,Lab C.) �E�a�RE�.1,�: APPtiCATtON FQR PERMIT � Rolicy No. Company ❑Cehified copy is herehy furnished. SEWER - SEWAGE DlSPOSA! �Cenifiad copy is filed with the coun�y building inspacrion n�OUNTV OF LOS ANGELE��.'� BUILDING AND SAFETY de rt n� ��e�4��b ����a��Van Diest & Son FOQ APPUCANT TO Fllt IN CONNECTION DATA CERTlFICATE OF EXEMPTION FROM WORKERS' ���p� 2�949 �• ��1 ��ll12 Dr. COMPENSATION INSI}RANCE �onaess siprwr+ oevrH (This aettio�naed no�be completed if the wwk involved 6y the �i�Ty r.w�acf[r�nec� i R' permit is for one hundred dollars(Z400)or lesa.) 1 certif �hat in ihe erformonce of�he work for which this cQ�osssss. n���T� t��7H�t Y P Y. NR6 P. . P.L. permit is issued,I shall not employ any person in any manner � P��� � so as to betome subject to the Workers'Compensation laws. pw�a The Z'� T�`OII CO. ro�^^v.�. �'v`a Teurxc v�RMir r+o Rano P[e�xrt r+o. Date Applicant °'°�REu . NO710E TO APPLICANT: If, af�er moking �his Cenifica�e of urv �i� a�F�onvn wn�vEa EASEMENi FKORD.iNSTq.NO. DAIF Ezemption, yov ahouid become s�ble« to rhe Workers' IEGAL Compensotion provisions of�he Lobor code,you must forthwith pExqi��p,i �ortao. �3 Hwv Oasr wio[Nwc � � �ply with such provisions or this permit shall be deemed ` kBd. BIOCK TFACT STA7E E 'FOACH NT � F IICENSED CONTRACTORS DECLARATION "A�B10GS ��� � 512E OF lOT NpW pN l0T 1 hereby offirm that I am licenaed under provisions oF Chapter us�o� Re9. 9(commancing with Sedion 7000)o(Division 3 of tha 8usi- auaoir�s cHartcrs ness and P�ofessions Code,and my license is in fufl force and � effad. co.nvAcrar V3T1 Diest & 5on cor�cr�c�r� LicenseNumbe� 376&14 Lj[ C�agg c �2 pp�E� ., •+ . REIMBURSENEMRE � d � COlthOCtOr V%3n ���"�'�' �QfC /��,���� 7 2 DISiRI�T NO GRWP MAP PR $$EO BY Q � CISY j'�OZL'a .--. iEt:N6.- � 1 6K GG U ❑i om eaem t under Sac. of ihe L.A.Co. SrniE 68, ut. P ���ti�� 37 4 u�5 C 42 �- � �� � o i Plombing Code and/or Sec. ot tbe �'�°. �`+CRIPfION OF wOaK Re � h� ; �ous�s�u�o canweeru+ero ,� OQ DATE �� VALIDATION uv+ + 8.8 P.C a de for I he io l lowinp reoson °�����e i SEPTIC SqNI[.SEEPAGE 411 OR V1 ATS aN0/0R D�INFIEt� ry� �,. � Dafe rqUSE gwrEv CDIvraECtItJC.7� Br /� . GRIVAT 1 Signoture cavr�cr aoortron.ai uoc.ors � . OWNER-BUItDER DECLARA710N Wo�T°M°us�s�v,�° OVFRHOW SEEPAGE Plf,DAAINFIELD 1 hereby affirm that 1 am exempt from the Contmctor's titense EXTN,CESSPJOL,DRYWELL,Ml1NHOLE Low for Ihe foilowinq reason(SeC10l1 7O3I.S,B1115l1@5!OIICI Rf0- AITER,REPMN OR ABANppN MqJ$E , feii�0�3 CO[lp�: SEWER OR D�SOOSAL SMSTEM , n 1,as owner of the property,oi my employees with wages as - 1 �heir sok compenwtion,will do the work cnd the siructure a t is rrot im�nd�d a of#erod for aole(Section 70M,8winass .. and Profeuione Cudej. OWNER'S Pefmit ; 'JQ �Q ❑I,as owner of the properiy,am exclusively controcYng with AUTHORIZAYION TOTAL FEE 27 5Q ._� f1 c � f; [p litensed cnNractwc to construct�he project(Senion 7044, I NAYE AT TMIS DATE A COMRACf WIiH TNE HEREIN NAME�CANiPACTOR TO I; Business and Professions Code�. [aar�[Cr rNe�eov[oeSCQ�eto cxignr.�owtwuc*o rH[weuc Seu�R n o • � e � �� CONSTRUC110N LENOING AGENCY � _ - 1 here6y affirm that�he�e �s o co�7�rocfion lending agency SIGNEDTHIS OAYOF 19_ t .• ��', � for ihe performante of jhe work for whith this parmit is am�r�R°° issued(Sec.3097.Civ.C.). owNcesnc[wr • - .- ,..- . —, ADD4E55 lendar's Name G Y� ,� ^t, ' lender's Addms � 1 tertify IFw1 f have read�his application and stme that�ha Obove InfWmotion is correcl.I agree lo comply with oll County � ordinances ond State laws regulating Pl�mbing and Sewere, ond hereby authorize represenrotives of fhis Counly lo eMe� - up n the above-mentia d property for inspectian purposez � �� ���� � �SigrwNre of Per �tteo Dole �i NEVERSE F011 E7I�UIMATORY IANGUAGi h 1 . . � _ w —L� �II � '�` �1 a: � I i I, - ` '"' :, � � ,1 . I ' - . . _ = "' c �:�:� .. _ ;Y -" ` , � ,.I , . . , .r.�. �. ^ = �'t ' S- ��:,` �� 1'.. I . � � S �� C t�� ``; . �. �' .T� � . ` ..1 . = - �_ ��,_ �: _ _ � ' �I ,` �:��. 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