HomeMy WebLinkAboutNo Permit Number (5) , 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
0 n�l � m Y.�v��� F � Y`� � � O � �� O " � .
a
z �no � ��„p`�Q Q.o°''C .. � U �, a � � m,� o •
� � o� x �'� p" d �.c
� qu �•�._� +°� ��,,V"`F° �°, : G?:� o3 � aaimd�
j-• �j,o ;�wo`o � +a.�.. �+ � �� Lo o�
d, a, � z'�� � �'h.edec° '« � ` � cs�.c da
,ru,�Zti � � a co� � y� d.�
�Yi : k ��� .. ;� v� 8 0 � V o.ar.e -
� FQ.' q �y.o baQ•�m {L� v ".�,. °' � "Q � •
US: p C � '��yV, N y O 4 y tl~i+, �,�a„O �� �'C���,�.. .
W a,a, m " m w1°� r,G ow,otiu ey� ��-
A � mb ° � �'^:`�00�' dtla' �i �`tiaa� o °" m,� � p
y c o i,``� ��o"w-0�,.� , „o � � 'tt`,y� V1 i`6
Pi a�+ aV $ � �.�y.�V i� �o �vyp., ����• � � � y •
AF O � Y M V� d.O H�ti C O OI C ro O F�C V� g-D Lt
H W� �, T� ,i'. e' O•�.2 �a1 a C� p l.O� o• b "
��y +� y m y �Le A aui'M �Q.��.`w w ti �¢ � �� m e� R •��,,
�+ ��„•y`1�'.}. tl�V��w ! C � Y d N��'� aP O.� N {+
tq ,, n:vm .. ,,:'Ni,�«ti� °' c � mxybr,, a o
�
QrT�'l �r'tt. �� ��'� �� ~v�cb � v°� � o•e���„�w�p� [�• �
� �'� C� M O��� b O! 4 ��L2 w L N �;M � .
°�an �,�a � �^•Lv "o.y, �.aa�N3*� o o �o +� iL a�S
a .0 y � c N � a � �+ o " . � � a� C
« y �•� �a � m � � ° � � �0'��9og.�m, ap � ar a�s �
� °� a�"�'o �n-� � K m�M.�y-n r; y o v � c,+.S,� Qa Q �
�. � �.A ��.���I�� A�w�.',❑�y«�CM C� � O� � . .
..i 0.�' '.�s't! o �., �
N
W
�
�
q �.� '
QF _ '
M
W
k
N
� •
f
�
a -
z
�
N
N `...
0
� �
�
Z
i �
Q y
C �
�
W
o ❑ z
N
Q F � �,��, oZ��$
' Y PO O ��``h a Z�n
� � �� a= .T.� r .
T j� U
d � 4� 20 ❑ ug G� .�❑ . .
Q � ��, �� � � Z� ��
z o °`c� � J s
zo U� aa z
� �m u�sa Cl �� s� 3�