HomeMy WebLinkAboutNo Permit NumberWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have o certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, or
a certified copy thereof (Sec. 3800, lab C.)
Policy No. Company
❑ Certified copy is hereby furnished.
J^ Certified copy is filed with the county building inspection
department.
DateA U186 Applicant Van : : Son
CERTIFICATE OF EXEMPTION -FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the work involved by the
permit is far one hundred dollars (5100) or less.)
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Dare Applicant
NOTICE TO APPLICANT:. If,. after making this Certificate of
Exemption,. you should become subject to the Workers'
Compensation provisions of the Labor code, you must forthwith
+mioly with such pron or this permitvisioshall be deemed
sr yoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that t am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and
effect.
License Number 376814 Lic. Class Cr 42
Contractor Van Diest we 4/4/86
❑ I am exempt under Sec. of the L.A. Co.
Plumbing Code and/or Sec. of the
B. & P. Code for the following reason
Signature
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Secion 7031.5, Buisness and Pro-
fessions Code):
J 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7040, Business
and Professions Code).
0 I, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Section 7D44,
Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued (Sec. 3097, Ci, C.).
Lender's Name
)6A61Zp
CE BOB IREV.,,B31 APPLICATION FOR PERMIT
SEWER - SEWAGE DISPOSAL
, COUNTY OF LOS ANGELES ILDING AND SAFETY
FOR APPLICANT TO FILL IN
C+O�NNECTION DATA
BUILDING
ADDRESS 21006 i ail -lhj Drr.
STATION DEPTH
`/
LOCALITY
MANHOLE REFERENCE U
DEAREST
CROSS ST
TYPE OF CONNECT I LENGTH FROM
Y. CURB P P.L.
OWNER ,VonCO.
P.0 NO
IMP. NO.
MAR
ADDRESS
TRUNK PERMIT NO. ROAD PERMIT NO.
AFFIDAVIT WAIVER EASEMENT RECORD, INSTR. NO DATE
CITY 7E1. NO.
LEGAL
2
DESCRIPTION LOT NO
HWY,ORST,.W1t7PARNG. .. .... _ ._
BLOCK TRACT T
STATE E
ND. OF &DGS.
PERMI
SIZE OF LOT NOW ON LOT
USE OF
BUILDINGS Pa
QiARGES
'{t
Diest & a0ri
CONiRAROR 1'^
CONNECTION CHARGE FEE
ADDRESS _
PEIMBURSEMENT FEE
TT,,1� 734-74
CFF; Norco TELNO—
r�
G
DISTRICT NO. GROU/ MAP D BY
STATERATE C.
LIC
SK PG
DOEMNO.
Arg
N1p. DE®R WORK FEE
"OUSE SEWER CONNECTING TO
PUBLIC SEWER
1 7 00
PI42
NAL
DATE VALIDATION
SEPTIC TANK. SEEPAGE TIT Olt
PITS AND/OR DRAINFIELD
FINAL
HOUSE SEWER CONNECTING TO
BY
PRIVATE DISPOSALSYSTEM
CONNECT ADDITIONAL BLDG OR
WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PR, DRAINFIELD
EXTN CESSPOOL, DRYWELL MANHOLE
ATTER, REPAIR OR ABANDON HDUSE
SEWER OR DISPOSAL SYSTEM
d I v il. i i ri
OWNER'S Permit s
10- j0
AUTHORIZATION TOTAL FEE
h P -
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO 1 s I
CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. -
- x
SIGNED THIS DAY OF 19_
OWNER OR
OWNERS AGENT
ADDRESS
Lender's Address
1 certify ?hot I have read this application and state that the
above information is correct. 1 agree to comply with oil County
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorize epresentotives of this County to enter
ups to above -me nedupa obove-me ned property purposes.
S nature of mitteeS nature of Dat. SEE REVERSE FOR 1011""TORY LANGUAGE
