HomeMy WebLinkAboutNo Permit Number WORKERS'COMPENSATION DEGIARATION
I hereby oHirm thal I hbve a certifimte of consent to Self �
�ns�re,or a certificaie of Workars'Compenwtioe losurance,or )bA617D
a certifiad copy th�reof(Sec.3600�LO{1 C.� CE811N�REY.1.'83i APPLICATION FQR PERMIT �
Policy No. Compony SEWER - SEWAGE DISPOSAt
0 Cenified copy is hereby f�rnished.
' � ertified coypy is filed with the counry building�nspection " '�' UNTY OF LOS ANGELES� BUILDING AND SAFETY
dePa4l�Fe/tiE v8S1 D185t G°c SOIS
�ate Appl�mnt FOR APFtICANS TO HLL IN <� CONNECTION DATA
CERFIFiEATE OF EXEhA7iFON FROM YVORKERS' g�npu.W
COMPENSATION INSURANCE wo�+Ess 2�0�� i:i. ilall Rllri DT• $��rwr�' �� e�erM
(This seclion need no!be tompleted if�he work invol�ed by tbe O fMNHpLE REFERENCE °��
parmi�is for one h�ndred dollars(5100)or lasa.) iacnurv
I certify thot in the pe�formance of ihe work far which this C�¢pF,�SgT ivaeorcor��c7 �[N[TNfqpM
permit is issued,1 ehat)not employ any person in ony manner Y� [uRe r 4 v.l.
so as to become suhject to Ihe Warkers'Compenwtion taws. Owr�R The e 021 L`0. CO.ihW.rp. P��N
��� fRVNKPERMITNO, qOADPERhVTNO.
Doie Appiicnnt aooq�ss
NOTI� TO APPItCANT� If, ofrer making fhi5 CBffi(ICa�B Of (jFY TEt.NO. ���DAVIT WAIVEG EASEMEM RKORD-INSTR NO DATE
Exemption, you ahould become s�bjec� to the Workers'
Compeasation provisions of the Labor coda,you must forthwith �s�tl�rr�ior� ioi no 4a wwv px si.w�o[iw'+c �
m �y with such provisions a�his permi�shall ba deemed
�� rd. eiocK TRACT � T LTAiE�T
140.OF 9IDG$ GERh11
� LtCENSED CONTRACTORS DECLARATION size a tor uow aN ior �/. ' �
I hereby uffi�m Ihat�am licensed under provisiona of Chopler ��
9(commencing wilh Section 7000)of Division 3 of the Busi- g�i�p��s a,u�s
�es�ond Professions Code,and my license is in fu�l force and i
BffBCi. [pNiRAROR v� Diest & Son CONNEC7IONCHARGEFEE �
v
ticense Number 376814i��.aa,s 4� �� C _ RElMBUNSEMENT FEE � �
Contrac�o+ V2S1 �iest �Date t�,/85 [rtr Ti07`CO ' �i.nio. . 2 wSTa�Crrio. v aur oar '
5,,,� �6si4 ,uc— C �2. � a�c vc � 3
❑I am exempf under Sec. of the L.A.Ca i���� �� l/j 7�� O �
Dlumbing Cade ond�or$ec. af fha �� DESCAIFTION OF WORK iEE F�Np� ��c'
Novs��wee conr�rnr+e ro �7 OG o-..n /j VAUDATION uV+ �
B.&P.Code for tha following reason °�K��R `�t/e� i4 ,
�PTIC TANK.$[EPAGE NT OR FMlAI N 3
vIT$qN0%OR DRAINfIELD x }
��e ilOUSE SEWEF CONNECTING TO B� j
VRIVA7 015 L iYSTE E
5�9��Uf8 WNNER AD�ITION�L BIpG.OR �
OWNER-BUILDER DECLARATION �K ro Nouse s�a �
OYERFLOW SEEPAGE RT,ppPMFIEID
1 heroby aftirm ihat 1 am exempt from the Contractor's License FxTN.CESSPOOt,DRYWELI MhNHOLE
L�W IOf tI1B fOIIOw1119 fea50f1(SfffO��CIS).S,BUISf1CS3 Ofld Pf0- PLTER,REPAIR OR ABIINDON HOUSE �
{RSf10n6 COdl�: SEWER OR D15POSM WSiEM � !,�f�L
I-�� os ow�ar of the ro ert or m em lo ees wi�h wa es as t
`�' P P Y, Y P Y 9 w�_ a a 7 r �
� pir sols rompensution,will do the wwk ond the structure ' ' - �� �
,not IMended or offered for sale(SeUion 7(14<,9usineu ,
andProfeasionaCode�. OWNER'S Pe�miT S 10 rj0 � ' °�1 t'':
❑I,as awner of the property,am exclusively contracfing with AUTHORIZATION TOTAL FEE 27 �j� � , - - �
licensed cannocrors ro construd the�O�OGi�$GCilon�OAA, 1 N�YE AT THIS DATE q COtJTRA�f WITiI THE HEREIN NAMFD COMRACTOR 70 � �l �
9usines5 and Profession5 Code. CONNECT TNE ABOYE DESCRIBED ExISTING OWFttING TO THE iU&IC SEWER. -
� ll��. ( .�,—��
CONSTRUCTION LENDiNG AGENCY � "
. 1 here6y affirm ehnt Ihere is o constr�ctian lending ogenty SIGNE�THIS DAYOF lg_
for the performonce of Ihe work for which this permit is °�^�^�p°R `
ixued(Sec.9697,Civ.C.). Ownecs nG�r+t }
nooaEss
lender's Nome
lendar:A�lress
I certify ehot 1�hove read this applKmion and swre that tha
above informotion is correct.1 agree to tomply wiih pil County
ordinantes and Sta1e laws ragulating Plumbing ond Srwrrs,
ond hereby ouihwize ep�ese�tafives of thi�Counfy to enror �
u he o6ove-ment' irod propeny for inspecrion purposes.
Siqnaf�reoiPe�l�tee e � ffEMFVHtSEiO�EXILANATO1WlANGUAGE �