HomeMy WebLinkAboutNo Permit Number (3) � WORKERS'COMPENSATION DECIARATION
' I heteby affirm that I have a certificote of consent to self ���PW 3�� . �
i �nsure,or o certifitofe of Workers'Compensation Insorance,or �0'��D �
, a certified copy�hereof(Sec.3800,�ob�.> `E� APPLICATION FOR PERMIT
Policy No. Compony �s
� ❑ry�Gertified copy is hereby fwnished. SEWER - SEWAGE DiSPOSAE
- P_1 Ceotifrritte��nnd copy is filed w�th rba counry building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
ame 8�,��/&� Applicont v�II I3�'e8t & SOII� IIIC. FOR APPUCANT TO FILL IN �L� CONNECTION DATA
� CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE awaes�.s 20731 East �.m I,n.� STATION 7 � cevrH �
� (This section need not be mmpleied if the work involved 6y the �wno�E aEr�aEnx� �� uv�cx
permil is for one hundred dollon($100)or less.) ��4L17Y
I carrify ihat in the performance of ihe work for whfch ihis �Rpusr. T�v�°F�°NNERKKI ��-'TMFROM
Y. CURB M.t.TO P.t.
permif is issued,1 shall not emplOy any person in any monner
so as to 6emme subject io�he Workers'Compensation Laws. � vt.r+o. Q y
OWNEB OSl CO.IMP NO. JOB NO. �
��� TRLLNK PERMIT NO. ROA�PEiIMIT Np.
Date Applicanr �DORE55 � '
NOTICE TO APPGCANT: tf, afre� moking this Certificate of nrF�oAvir wnrvea ensc,weNT Rcmao irisrx.r.q. onTE
Exemption, you should become subject to the Workers' ��T� 7EL NO.
Com nsation avisions ot the Labor code, ou must forthwith �EGA� �3
PQ P� Y DESCRiV110N LOiNO. HWY.ORST.WIDFNING
comply with such provisiont or this permit sholl 6e deemed
f@VDIfB(J. BLOCK TRAR STAtEENCRpACMMENT
LICENSED CONTRACTORS DECLARATION ��� r'°. f�°�s. �KMii N°
SIZE OF tOt NOW ON LOT /� �/�/
I here6y affirm ihat f om licensed under provi:ions of Chopier �� xpy. �7
9(commeixing with Section 7000)of Division 3 of the Busi- ew�oiN�s $@S �Aq�g
ness ond Roteuions fode,and my license is in full force and
effed. mvrRaciov Van Diest & Son IIIC• cor�Necnora cwzc,�ree
licenseNumber 37b8�4 Lic.Class C' 4� aooaess 1q.9¢ Ii�mner Ave. #' .� aEimaux�MeNTvee O
COnIrOC�Or V?..II DZ3� DotE �,,L/H7 N�Z,L•� TE�.NO ?Z �7 2 �ISiRICT NO. GROUP MAF Pqp�ESSED BY (�
CI1Y �J Z
5,s.� 376e�4 �� � ¢2 � � aK � D , o
❑i am exemp�under5ec, of fhe L.A.Co. uc�Ns�No. anss
�. DES�RIPTION OF WORK �[ r
Plumbing Code ond/or Sec. of the c!unt U
HOUSE SEWER CONNECTING t0 oare �� � �� VALIDATIQN a
B.8 P.Code for ihe following reason - PuauCSewea 17 Q�
� SEPTIC SANK.$EEPAGE PIF OR F�� $
PIiS Ah0/OR ORA!Nf�ELC
ODt9 IqUSE SEWER CONNEC7ING TO BY /
PRIVATE DISPOSPl SYST �
Signoture CONNECT ADDIiIONAL BL�C'i.OR �
OWNER-BUflDER DECLARATION W�RK TO HOUSE SEWER
OYERfLOW SEEPAGE Cli,ppAINiIEID
1 hareby affirm ihol I am exempt from the ConKactor's License EXTN.,CESSP.'J�L,DRYWEGL MANNOIE
lbw for Ihe foHowing remon(Secton 7031.5,Buisness ond Pro- ntrea,qEvn�R OR A&4NDON HOuSE
fQ54iOf15 COdC�: SEWER OR�ISPOSAL SYSTEM
❑!,as owner of ihe proparty,or my employees with wages os
fheir sole compenaation,wil4 do�he work and Ihe structure `V,K�q q
is not intended or offered for sale(Section 7044,8usiness
ond Profess�ons Code). OWNER'S Pe�m�� S �� SO �� , . � � �
❑1,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE '27 5� n
I1CefiSEd CO�hOCf�fS�O COn511UCt tI1B PfO�ECi(S2C1iOf1�044, I HqyE Ai iHIS DATE A CONiRACi WITH iHE HEREIN NAMED CONTRACTOR TO � � ����J v
BUSifiC55 Ofld P/OfC5510n5 COdO�. CONNEC7IHE ABOVE DESCRIeED E%ISiING DWELIING TO THE�UBIIC SEWER.
CONSTRL)CTION LEND�NG AGENCY � � • � ��7,'J C=
I here6y affirm 11wt there is a conslruCtion landing agenq SIGNE�THIS � DpYOF � � 19_
for ehe performance of the work for which this permit is o`"i�ER°R . � Q�l J�—�7
IlStlCd(SGC.3O9J,CIY.C.,. OWNERS AGENi
A��RE55
tender's Nome
lender's Address
I certify thut 1 hove read this application and state that the
abova information is corred.t agree fo comply with all County -
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorire�epresenfotives of this Coonty to enter
upon tha obo e-menfioned property tor inspection purposes. '
� -r'fl�r�.�•�.�---- ��3� '-��
Sign�o vl�f of Permitfee Dafe SFE RFYERSE POR EXPLANATORY LANGUAGE ,
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