HomeMy WebLinkAboutNo Permit Number , WORKERS'COMPENSATION DECLARATION
I hereby aHirm thoi I have a cenificate of consen� io self °�-o°°�ovw aie� , �
insure,or a certificate of Warkers'Compensatinn Insu�ance,or �°A°���
a certified copy thereof(Sec.3800,lab C.) `�� APPtICATiON FQR PERMIT
Policy No. � Company . �s. . . . . -.
❑Certified copY�5 he�e6Y f����shad. . -�SEWER--�SEWAGE DISPOSAL
�]Ceriified copy is tited with the county build�ng inspec�ion COUNTY OF LOS ANGELES BUIIOING AND SAFETY
depariment �
Dut�,31�8', Applicant Pan Diest FOR APPIICANT TO PILL IN f O CONNECTION DATA
CERTIFICATE OF EXEMPTION iROM WORKERS' eunomic �7�5 �t � �e sinrioN ��G� �ocm+��
COMPENSATION INSURANCE aooaess
�This section need not be completad i{the work involved by the ���T� , r.ur�HaE ae�a¢r�c,� �� � � - �R
permit is for one hundred dollars(S��)or Iess.J �qpEST v TYPEOFCONNECfI�N {�ryGTHfROM 2 i
I certify that in the performance of the wark for which this �RpS54. y_ [ugg .�. M.LTOP.1. �'
permi�is issued,I shall not employ any person in any mannai , �,
so as fo bemme subjecf io ihe Workers'Compensation Lows. owNER m.inna.nw. Poe r�io-fC� ��
�'�� iRl1NKPERMIiNO. ROADPERMITNO.
Dote Applicant A�DRE55
NOTICE TO APPLICAM: If, aftar mafcing ff1i5 Certificate Of CITV TEL.NO- AFfIDAVIT WAIYER E0.5EMEN� RECORU.INSTR.NO. OAiE
Exemption, you should become subjeci ro !he Workers' iE�a�
Compenaation provisions of tbe Lobor mde,you must fo.thwith oEsca;v�iQa iot rio. � irvvv.ort sr.wioewN�
comply with such previsions or this permi�shall be deemed
revokad. eiocac TRACT 376s14 STATE ENCROACHMENT
LICENSED CONTRACTORS DEC�ARATION NO.Of Bi�C'i5. F'ERMIi NO.
52E OF LOT NOW ON lOT �/
I here6y o4firm ihnl l am li[ensed under prOvisipns of Chapter ��� ;�-C c�L�y ��
9(tommencing wifh Section 7000)of Division 3 of Ihe Busi- -- auiimu�s Res. cHnx�s
ness and Rofessions Code,and my(icense is in full force and .
EffCC�. CONTRACTOR Yan Diest & � Z'j CONNEC�ION CHAR�E FEE
..�_.4A�_ y
License Number 3768'�4 �I[.C��SS��� qpORE55 1494.x�er Ave. A REIM9URSEMENT ffE a
0
CDnha[to� Y� �QSt �Ole �3��7 DISTRICT NO. GItOUP MAP PROCESSFA 8Y V
CITY �El.NO.
STATE �S� C�� '� BK PG z
❑I am exemp�unde�Sec. of the L.A.Co. uc¢Ns�r�o. (i` 2 �-1 � O
NO. DESCRIPTION OF WORK FEE ' ~
Plumbing Code and/or Sec. of the FwAt V
HOUSE SEWEF CONNKfING TO �AiE $ VALIDATION W
B.&P.Code for the fo�lowing ieoson °������^`�R � a
$EVTI�TANK,SEEGAGE PIT OR �
�fe VIT$ANO/OR ORAINF�ELD F�'� � ?
fqVSE SEWER CONAIECT{NG f0 BY
PRIYATE DISPOSAL SYSiEM.
Signature CONNECf ADDITIONAL BI�G.OR �
OWNER-BUIlDER DECLARA710N � woaK ro MouSE sEwEv
MERFIOW SEEPAGE PIT,DRAIM1FIEID
I hereby affirm that I am eaempf hom the Contracror'e License , [xrN.,c'�sscoot,oRrw[u,MnNHo�
� law for the foflowing reoson(Secton 7Q31.5,Buisness and Prv- ratFu.ueaniR ow nenNooN House
fessions Code�: SEWER IXt DISiOSAI SYSTEM �/��"O!`❑
V�U Y r�
Q I,as owner of the property,or my employees with wages as �. �
iheir sole compensation,will do tha wo�k and the slructure t'� � � � V
is not intended or offered for sale(Section 7044,Business
ond Protessions Code). OWNER'S Pe�mit E � + •C����i
❑I,as owner of the praperty,am exdueively coniractin9 wuh AUTHORIZATION TOTAL FEE • � •2!,rJ��
li[ens9c/[oniro[lors fo consiruci the projecf(Secfion 7�44� 1 HAVE AT THIS OATE A O�N7FACT WIlN THE HEREIN NAMED CONiRACT R TO
BuSifiB58 tl�E PfOfgSSiOns CO[Ie. CONNECT THE ABOVE DESCRI9E�EX15?IIJG�WELLING TO THE PUBLIC SEWER.
� � �.�5'07
CONSTRUCTION LENDING AGEMCY � .
I hereby aHirm fhot there is a mnsfrucfion lending agency SIGNEDTHIS DAYOF �9_
' far the performance of the work for which ihis permit is owra[as�er+T
issued(Sec.3097,Cir.C.). -
PDDRE55
Lender's Name .
Lender's Addresa
1 cerfify that I hove read this appli<otion and state thai the
obove Information is rorrect.i agree to comply witb all County
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County�o emer
upon �above- en jon oparty for inspection purposes.
�`�� �-���
Signat e o+Permittee Date SEE REYERSE FOR FXPIANATOkY LANGUAGE
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