HomeMy WebLinkAboutNo Permit Number (134)WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, or
a certified copy thereof (Sec. 3800, Lab C.)
Policy No. Compony
yyEl ��C��ertified copy is hereby furnished -
`M' ertifted copy is filed with the county building inspection
dePZ7TJy6 Van Diest & Son
Datttiie Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the work involved by the
permit is for one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this
permit is issued, 1 shall not employ any person in any manner
so as to become subject to the Workers' Compensation Lows.
Dote 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
rr ty with such provisions or this permit shall be deemed
` rd.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I 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 37 $1 ¢lic. Class v42
Contractor Vaal Diest Date A/4/85
❑ I am exempt under Sec. of the L.A. Co.
Plumbing Cade and/or Secof the
B. & P. Code for the following reason
Date
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License
Low for the following reason (Secton 7031.5, Buisness and Pro-
fessions Code):
nI
as owner of the property, or my employees with wages as
ittt Bir sole compensation, will do the work and the structure
not Intended or offered for sale (Section 7041, Bush—
and Professions Code).
❑ I, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Section 7044,
Business and Professions Code).
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued (Sec. 9097, Civ. C.).
Lender's Nome
Lenders Address
I certify that I hove read this application and state that the
above information is correct. 1 agree to comply with ail County
ordinances and State laws regulating Plumbing and Sewers,
and hereby outhorim eprie ntatives of this County to enter
u he above-ment) rad properly for inspectionpurposes.
Signature of Pepnlitee Ddie
76A6d7D
CE Wa TREY. 1,T31
BUILDING
ADDRESS
LOCALITY
NEAREST
CRoS-S ST
OWNER
MAIL
ADDRESS
CITY
LEG
AL
DESCRIPTION
BLOCK
SIZE OF LOT
LASE OE
BUILDINGS
CIXJTRAROR
ADDRESS
CRY NO
APPLICATION FOR PERMIT
SEWER - SEWAGE DISPOSAL
F OF LOS ANGELES�C BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
The &Lyon Go.
Van Diest & Son
10ENSE No. 3458 4 cl`ARS C 4'<
NO. DESCRIPTION OF WORK FEE
NOU5E SEWER CONNECTING TO
PUBLIC SEWER
SEPTIC TANK, SEEPAGE PIT OR
PITS AN 0R
DRAINEIELD
Hous, SEWER CONNECTING TO
PRIVA7 DIS L SYSTE
CONNECT ADDITIONAL BLDG. OR
WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT, DRAINEIELD
EXTN. CESSPOOL, DRYWELL MANHOLE
ALTER, REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
OWNER'S Permit s
AUTHORIZATION TOTAL FEE
I HAVE AT TH15 DATE A CONTRACT WITH THE HEREIN NAMED CO
CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC
SIGNED THIS DAY OF
OWNER OR
OWNERS AGENT
ADDRESS
FEE REVERSE FOE EXPLANATORY LANGUAGE
�CONNECTION DATA
STATION DEPTH
MANHOLE REFERENCE
U -
OF CONNECT
Y. CURB
IFNGTN FROM
P 1 P.l.
CO. IMP. NO.
PC. N
TRUNK PERMIT NO,
'NT
ROAD PERJTRNO
AFFIDAVIT
WAIVER
EASEMENT RECORD -IN
HWY OR ST. WIDENING
LTAiE $V�CHMENT
PERM(
wt
CONNECTION CHARGE FEE
REIMBURSEMENT FEE
DISTRlCr NO.
PA4AP
INK
112
—JAY I VALIDATION