HomeMy WebLinkAboutNo Permit Number WORKERS'COMPENSATION DECIARATION I hereby affirm tha� I have a certificate of consent to self `� insura,or o cerrificate of Workeri Compensotion Insurance,or �6^6<2o II a certified copy the�eof(Sec.3800,Lab C.� ������-�� qppE�CATiON FOR PERMIT " Polity No. Compony y❑�Cerfified capy is hereby furnished. SEWER • SEWAGE DISPOSAL 'C]Certifiad capy is filed with+he counry building inspaceion .�' � COUNTY QF LO$ANGELESI t,r B�l� ING AND SAFETY depanment. �'�� Do�� a/a/a6 npplican� y'� Dlest & Son FpR APPtICANT TO Fllt 4N a CdNNECTION DATA CERTIFICATE OF EXEMMION FROM WORKERS' �iip� , COMPENSATlON INSURANCE �onacss 2O - c'�11 $L711 1�T� surww � oErrH (This sec�ion need not be completad if ihe work involved by the ia�itY Diamoncl•��S MANMIXE REfERENCE permi�is for one hundred dollars(S��)or less.) �. 1 certify tlw�in the perfo�munce oi�he work for which this �cp ggi rvv�oFcaHn[CtioN �r�tHpkor�' '�, permit is issuad,i shall not emplay ony person in any monner /� Y� NRB v.i . v.�. i so as 10 become subjetf 10 Ihe Workers'Compenwtion laws. oN,�R ltl@ �v`ID�071 yO♦ � �O��� P�.N� i r.aai I Oate ApPlicant �OORE55 TRIINK fERMJT Np kO�p r4cn�n rap. NOTICE TO APPLICANT: If, afrer making this Certificate of AffIDAYiT WAIVER eesEnneNr Q[CpRp INSTR.NO os.n orr i[i.r�o. Ezemption, you shoutd become subject ro �he Workars' Compensm�on pro��s�ons of the tabor code,yoo must forrhwith pesceivrior� wrra. � MWY.OR ST WIpENING ; �ply with such pmvisions o�this permit shol!be deemed 431b2 z1 � � �ked. a�acc rRncr � s�re _. _ .. _ . _ UCENSED CONTR.4CiORS DECLARATION ^+o����� size or cor rvaw pn�ipr I hereby affirm thot I am licensed under provisions of Chopter �a . yl �� 9(commencing wi�h Section 7W0)of Division 3 af the Busi- g�i�p� $�g. �.�5 neu and Professions Code,and my licanse is in full foree pnd t1 BME[f. �pNTIiACTOR p i.3'1 D1P.3'� & J�n �ONNEC110N CMARGE FEE LicenseNumber 376e1� Lic.Class �+ 42 �ppQEu 14gn, K'iII7!'!QI' t":V2• �� � :� RFIMBVRSEMENi FEE Contractor Vjr. Tliac�h Date�,l��R�i .. Girr xorcc � .E�,�. 734-7442 wsTaKrwo. Gaouv Mpp sY O � Q.I om exempt�ndar Sec. of the L.A.Co. 5'�TF �'� � q. uc (�+ 42 �1 � � � ,//JyA A J`/ U I�CENSf NO. CLA55 C'.y' �� V�`�7 — C: NO, DESCRIPTION OF WORK fEe i P{�mbfng Code andlw Sec. of ihe nN�u O NOUSE SEWER CONNERIhIG T0 �7 pp OATE YALIDASION v WBU[SEWER �7 W B.8 R Cvde for�ha following reoson K ANK,$[Evq�%T pR rP� iITS ANp/OR DRAiNFIELD fINAL � �fe HOUSF SEWER CONNECTING Tp dY 'Z PRIYA �I !SY iE � Sig�01U/9 [OryN[�T Applfipµ,H glpG pp OWNER-BUILDER DECLARATION wORK Tp NWSF SEWER WERF[OW SEEVAGE%T,DRAINFlELO 1 hereby affirm Ihef I pm e:empt from the Confrattoi s License E%iN CESSPOIX DRYWELL nuNHoie <=�� �'"�F� law for the lollowing reoson(Sec�on 7031.5,Boisnese and Pra- rurea.2evnia oa nenrvoorv'qus¢ � SFwEG Oli DI$PpSA(y/STEM +�� feasions Code): n . . . 1 � , n 1,as owner of�he property,or my emplayees with wages os f Y _ � 4 their sole compensotion,will do the work and the s�ructure L ���L � '�. is not intended a offe�ed for wle(Seclion 7041,Businesa _ .,_ ondvrofessiomCode). OWNER'S Permit s � -._�� , � i ❑I,os owner of the properry,am exctusively conrracting with AUTHORFZATION sOTAL FEE Jµ j �—;��h It licensed mntractors to construct the project(Section 7M4� �{�p,yE qT iNIS OALE A CONTRA�'f VyITN iNE HEFEIN NAMEO CQVT ACiOR TO � Busineu and Mofesaions Codaj. cor+ni[cr rH[rsove oescaiaeo exisnnc owcuuac ro t�vusuc S�wErt. CONSTRUCTION LENDING AGENCY � I hareby affirm that Ihere is a conslruction lending agency S�GNEDTHIS DAVOF iq_ for ihe parformonce of ihe work for which ihis permit is �R� Issved(Sec.3097,Civ.C.�. OwNFRS AGENT MDRE55 j lender's Name ` i Lender's Addreas i �certify lfwt 4 have read�his application and ata�e Ihat the i o6ove fnformmion is mrrec�.I agree to comply with oll CouMy , ordirwnces and Stale lows regulnting Plumbing pnd Sewers, � � and hereby autharize represenfotives of this County eo enter i j u he obove-meniion property for inspection purposes. i Signotura oi Por iHee Dol9 v fE!NEYE�tE FO�E7(KANATORY LANGIIAGE i � i i \ '\ � _ '- . ,� `. \ �\ ' `\ ' .. � �..� . � �����Y`�. . r ^ � . � ' \\ ' . J '� " .. _ ^C.`C... •r ' CsC _ � ... ,'1' ` , . . � •yv��.-y �'`G_' � '^� +:t`. ,_ 'j ��„ '�^ ^�.:. -_ 1� \ ' • r +•i' _~� =� ~'«� .._.�. - 4 _ _ _ A . . . � � ^s 'i'. C "r J�, � '� ',� J �3` 'L' � ,L~ � ^'1 !. ' .�� p 1\ ` ' p, i.� c� _- _`'= %'_ -.-c•- __'- -�L'.- `` �y \ - . � ' ;�„�: _ _ . �c�.� � _�c:.� - " d_ '' \� � , ��y� !' �,� . � ' ' - =Y.r. . ` � ,� � _ .. '\ i . .. � � ;� '�. C .. �. ��. � = � - � � � ... � � �' rt '� !: . r r .� '= � ' �f' ��G. - : �. 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