HomeMy WebLinkAboutNo Permit Number (174)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, Lob C.)
Policy No. Compony
❑ Certified copy is hereby furnished.
JMCertified copy is filed with the county building inspection
deportment.
Date 86 Appii,an, Van Diest & Son
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.)
1 certify that in the performance of the work for which this
permit is issued, I. sholl not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor cod", you must forthwith
-omply with such provisions or this permit shall be deemed
s yoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 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 37681 r' Lic. Class C A2
Contractor Van Diest 1,,e 4/4/86
❑ I am exempt under Sec, of the L.A. Co.
Plumbing Code and/or Sec. of the
B. 6 P. Code for the following reason
Date
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License
Law for the fallowing reason (Secion 7031.5, Buisness and Pro-
fessions Code):
❑ I, 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 7044, Business
and Professions Code).
❑ I, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Section 7041,
Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm thot there is a construction lending agency
for the performance of the work for which this permit is
issued (Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
1 certify that I have read this application and state that the
above information is carred. I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upon the above -menti ed property for inspection purposes.
rdApd7D
CE808 IREV. 11831 APPLICATION FOR PERMIT
SEWER - SEWAGE DISPOSAL
. V316i ,.6�UNTY OF LOS ANGELES �"UILDING AND SAFETY
FOR APPLICANT TO FILL IN
<)
CONN CTION DATA
ALALORRIESSS 21o36 r. (�,uail Run Dr.
sTATKX+ -7 4oEPrH
_
.
LOCALITY
MANHOLE REFERENCE
U 4 1 5
NEAREST
CROSS ST.
TYPE OF CONNECTION lEN<aTH p
Y. CURB P.L. TO P.L.
OWNER The ldmlyon Co.
OD IMP, NO.
ADD
ADDRESS
TRUNK FERMn NO. ROAD PERMIT NO
AFFIDAVIT WAIVER EASEMENT RECORD. INSTR. NO
DATE
CITY 4E1. NO.
I
LEGAL
DESCRIPTION LOT NO. 37
HwY. OR ST, WIDENI
TpNG
BLOCK TRACT 162 I1
STATE ENCROACHME
NO. OF BLDGS
PERMIT
S12E OF LOT NOW ON LOT
USE OF
BUILDINGS Rs
CONTRACTOR yrs D,_est & Son
CONNECTION CHARGE FEE
ADDRESS A1
REIMBURSEMENT FEE
=613—
CITY No O TEL. NO.I
DaTRICT NO GROUPSSTANSE
NO 376814 CLASSc
2
,c/DESCRIPTION
No OF WORK FEE
-HOUSE SEWER CONNECTING TO
FINAL
DATE
BLIC
17.00
�� 3 �— VALIDATION
SEPTIC TANK, SEEPAGE PIT OR
NTS ANDIOR DRAINFIELD
FINAL
HOUSE SEWER CONNECTING TO
By
PRIVATE I Y TE
CONNECT RDG. OR
WORK TO HOUSE SEWER
HOUSE SEW
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN. CESSPOOL DRYWELL MANHOLE
ALTER, REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
OWNERS Permit s
10,50
1 4 c, 5A
AUTHORIZATION TOTAL FEE
2700
... 1
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
<)
CONNECT THE ABOVE DESCRIED EXISTING DWELLING TO TIE PUBIC SEWER,
SIGNED THIS DAY OF 19_
OWNER OR ®
_
.
OWNERS AGENT
ADDRESS
U 4 1 5
Signature of Per tiaee Date �— SEE UVUU MR EXPLANATORY LANGUAGE
6
O
U
dx
FO
U
lu
Ztrl