HomeMy WebLinkAboutNo Permit Number WORKER$'GOMPENSATION DEUARAiION
I heraby uffirm that I have a cenificme of consen� �o self 57
insure,or o certifimte of Workeri Compensation Insumnce,or �d'WZ� �
a terlified copy thereof(Sea 3800,Lab C.) CE80BIREV.L83� qpp��CAT10N FOR PERMIT
Policy No. Campony SEWER - SEWAGE DISPOSAL
❑Eertified cnpy is hereby(urni:hed. ,
s�Cerri4ied copy is filed with the county buiMin9 inspecrion � (�f�i` ��uNTY OF LOS ANGELES�� UICDING AND SAFETY
� deportment.
p„e 86 ,�i;�,,,, yan piest & Son fOR APPLItANT TO FILL iN CONN CTION DATA
CERTIFICATE OF ExEMPT10N FROM WORKERS' ����� 21036 �. �,U31.� RllTl DY'. srwrpra peprff
COMPENSATION INSURANCE " �ooaess
(This setlion need not be completed i(the work involved by the i��iT� hWNHOLE REFERENt�
perm��is for one hundred dollon{$l0U)or less.) _ .
1 certHy that in the performonte o4 ihe work for which lhis ��REsr � rrffacoNNeeT� ��MF�
�ROS55T. Y. CVRB P.L. . TOP.L.
perm�t is issued,I.shnll no�employ any person in any manner
• so as to become subject�p rhe Workers'Compenwtion Laws. p,N�p The '�l 011 L'O• CO.IMV.Np. P C N
m•n � rauwc v�xr.ut r+o. awo v�RMrt r+o
�ate Appliwnt �Eu
NOTICE TO APVIICANT: If, ofter making this Gertificate of AFFID.4V1T WANER f15Eti+a�T MFCOqD.INSTfI.NO wrt .
Exemption, you should 6ecome subiec� to the Workeri ��TM sE�.�'
Compensation provisions oi the Labor coda,�you must forthwith p¢sc�iora WT NO. NIMY.pRST.NA�EMNG
romply w'rth soch prorisions�w fhis permit shaH be deemed �7 T I
'�, i�Oked. � � � &OCK TRACt �62 dT STAiE ENCROA�VIME I
� tlCENSED CONTRARORS DECIARATION PER""'T
512E OF l01 rypy/pd Lp75 a I
I hereby affirm that 1 am licensed unde�provisions of Chaprer �� �
4(tommancing wirh Section 7000)of Division 3 of the Busi- ewcar�s RS a,�y �
nesa ond Professiona Code,and my licenx is in futl force and
BH@�L �pNTYACfpR Van �iest & Son CONN[[TION CHARG[FEE
Licrose Number �EiB'�� Lic,qass C �2 _ �
AODRE55 n 1 RFiMBURSEMENf fEE
Contractor v`'n D7-eSt Dare �?/4/86 � Id0 o reiwo oarR�crNa cna�v MAP DBY Q
aTv — � �
❑I am exempf u�er$�. of Ihe L.A.Co. l���,p 376g�4 ��A55 c 2 �, C3 �J1 sl/_('� � �
LJ6.j�dtv
PlumbingCodeand/ar5ac. offhe �� ��IPTIONOFWORK �E rrNat �
N�OUSF��q CONNECiM1G TO 1 00 °"'E .��3�— VALIDATION �
B.6 P.Code for the following reoson iTIC TANK,SEEiAGE i1T pq W
Dore wu�wo�oa oaninai¢�o � cw�u �
FqVSE SEWER CONNECTING�O eY Z
ViWATE 1 Y TE
SignaWre WNl�crn�urtqNAl%pG.oR �
OWNER-BUILDER DECLARATION �pK TO���WER
I hara6y nffirm Ihvt 1 om exemp!from Ihe Coniracloi s license �TMF�O�WS SF�EY�i�p�DRAIMNniNIHaE
Law for the falfowing reason(Seclon 7031.5�BUi4�043 O�d P!O- AIIER,REPAIR pR A9ANDON NOl15E
fessions Cade): stwcR a+wsros�t sv5itrn
r ❑I,os owner of ihe property,or my employees with wages os �
their wle tompensation,will do the work and the srructure
\. is not in�ended or offered fa wle(Section 7044,Business
ond Professions Code�. OWNERY Permit f 10 0 �} (y G!�,y
❑I,os owner of�he properry,am exclusi�ely contracting with AUTHO(1FZATION TO'iAl FEE 2`] 50
licensed wntroctors ro construct the project(Section�OM, 1 HAVE AT 7N15 DAIE A[IXJiPAR WITN iHE HEREIN NAMED CONTRACT6R TO �� ° � • I U
Business ond Rofessions Code). corat�ttr iHe naovE ocscaiaeo exisnNc owetur+e To rN[wetK sewee,
CONSTRUCTION LENDING AGENCV � " ' G�.::•�'
I hereby offirnl th0� there is a conslruction lending agency SIGNED7H15 DAYOF Iq_ _
far the performance of rhe work for which this pe.mit is �NER OR c � . - ,
iuued(Sec.3097,Civ.C�. ow�°S�Ni � `-.,
�ooRess U u 1 7—'.-��b
Lendar's Name
tender's Address
1 cerlify thof I have read Ihis application ond smte thol the
above informotion is cwred.I ogree to comply with all Counry
ord�nances ond Stote lawa�egulating Plum6ing and Sewert,
and ha.eby authaize represemdives of ihis Counry ro enter
upon�ha a6ove-menfi ed prOperly fOr inspection purposes.
� �zt�a�i��7—��
Signafure of Per �iMea Dote �— SEE RLViRf!FO�EX/lANA70kY LANGUAGi ' �