HomeMy WebLinkAboutNo Permit Number (151)WORKERS' COMPENSATION DECLARATION
I hereby offirm that 1 have a certificate of consent to self
insure, or a certificate of Worker&' Compensation Insurance, or
a certified copy thereof (Sec. 3800, Lab C.)
Policy No. Company
❑Iq},rC�ertified copy is hereby furnished.
CDCertified copy Is filed with the county building inspection
department.
Dote4.,1 Applicant Van T)3 oat P. ScIn
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, I shall not employ any person in any manner
so as to become subject to the Workers_ Compensation Laws.
Dole Applicant
NOTICE TO APPUCANT: If, . after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor code, you must forthwith
ply with such provisions or this permit shall be deemed
:ed.
LICENSED CONTRACTORS DECLARATION '"
f 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 376814 Lic. Class
Contractor n TI;o-t -Date4,1446
❑ I am exempt under Sec. r+f the L.A. Co.
Plumbing Code and/or Sec. of the
B. 8 P. Code for the following reason
Signature
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License
Law for the following reason (Secton 7031.5, Buisness and Pro-
fessions Code):
.f1 1, as owner of the property, or my employees with wages os
heir sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7014, Business
and Professions Code).
E] 1,
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 offirm that 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
I certify that 1 have read this application and state that the
above Information is correct. I agree to comply with all County
ordinances and State lows regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upo a above -mention property for inspection purposes.
1 iA2 ��
Signature of Permit ee Date
CE 805`REY 1/0" APPLICATION FOR:FERMI_T
SEWER - SEWAGEDISPOSAL _
COUNTY OF LOS ANGELES J,,j., .3Q_BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
7TT73 CONNECTION DATA
BUILDING ,� -
211 066 Run ]}i•
.. .. .. .. .
STAitgv DEPTH
ADDRESS G• Quail
LOCALITY
AYINHOLE REFERENCE
`. OWER
NEAREST - -
TYPE OF CONNECT K7N - FROM
CROSS ST.
Y. CURB P.L. M.. TO P.t.- _
v.c
OWNER The 'V OT1Co.MP
Co. I_NO.
MAR
ADDRESS
TRLRet pERAVT NO ROAD PERMIT NO.
N
AFFIDAVIT WAIVER EASEMENT RECORD INSIR. O DATE
CITY TF1. rm.
I I
LEGAL
DESCRIPTION LOT NO. 32
HWY OR ST WIDENING
BLOCK TRACTSTATE
E. NI
fEf)C>S
PERMIT
SIZE OF Lot NOW ON LOT
USE OF
Res.
BUILDINGS
pgRGES
ry�
CONTRACTOR Van Diest & Son
CONNECTION CHARGE FEE
1494 Hamer Ave. y A
REIMBURSEMENT FEE
DISTRICT Na. P AAP D BY
il0'fCIT RI. NO, Ci.C.
731-7n
2
BK PG
STAE No. 376814 I.C.
C 42
DESCRIPTION OF WORK FEE
FINAL
HOUSE SEw�EY CONNECTING TO
1•0
DATE VALIDATION
PUBLIC
SEPTIC TAM(. SEEPAGE NT ORFINAL
PITS AND/OR DRAINFIELDHOUSESEWER CONNECRINIGTOCONNPRNATEDISPOSAL
SYS1EWORK
[ADD11,11
T T HODITE(N�IAI R OR
WORK CT HOUSE SEWEROVERFLOW
SEEPAGE PIT, DRAINHELD
EXTN., CESSPOOL, DRYWELL. MANHOLE
ALTER, REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
OWNER'S Permit
s 10.50THORIZATION
TOTAL FEE
27.50VE
AT THIS DATE A CONTRACT WITH THF HEREIN NAMED CONTRACTOR TONECT
THE ABOVE DESCRIBED EXISTING DWELLING TO INE PUBLIC SEWER.
• ° i. 7 J U
SIGNED THIS DAY OF
I9_
® b iL l 5-86
OWNER OR
OWNERS AGENT
ADDRESS
SEE YEVERSE FOR EXRANATORY LANGUAGE - - - -
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