HomeMy WebLinkAboutNo Permit Number (125) � WORKERS'COMPENSATION DECIARATION
. 1 here6y affirm ihat I have a ceriifimte of consent to self ���oPw sia� q �.
insare,or a certifimte of Workers'Compensation Insarance,ar 10A6�2D LS �
a car�ified copy�hereof(Sec,3800,�ab�., "� APPUCATION FOR PERMtT �
Policy No. � Compony... ... . .. . .. . 0s
❑Certified copy is hereby f�rneshed. SEWER - SEWAGE DlSPOSA!
�Certified copy is filed with rhe tounty b�ilding inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY ,
department.
Dare 8 '1 8 APPliconr Y3t1 Diest Lc Son, IriC. FOR APPUCANi TO Flll IN .f� CONNECTtON DATA
CERTIFICATE OF EXEMPTION FROM WORKERS� � punnin�G � .
COMPENSATION INSURANCE AOORESS 2o73g �,st x.i�n Ln� STATION ��� oevrH�
(ihis section need not be completed if tbe work invoived,by the �,�(�(�, B�.` .. AMNHOIE REFERENCE � .� uvare
permit is for one hundred dolfars($100}or less.` ��'�R�
� � NEARE55 TYiE OF CONNERION IENGTH FRQM
I certify,tho�,in �he perfo.mance.of_the work for..which this caosssT. � v. cuce P. M.ITOP.I.
permii is issued,1 sholl nol employ any person in any manner t.i,.,T".' cy
so os to 6amme subject ro tbe Workers'Compensotion laws. ov,,NER a+"+y�n m.ir.�v.r�+o. ma Np: ��l5 {
Mnit
DOIB A(JPIiCOnt AD�RF55 TRl1NK CERMIT N0 ROPD PERMIT NO.
NOTICE TO APMICANi� if, affer moking ih15 Certifimfe Of CIiY iEl.NO. AFFIDAVIT WAIYER EASEMEM RECORD.tNSTR.NO. DATE
Exemption, you shouid become subjeU to �he Workers' ���
Compenw�ion provisions of�he la6or code,you musr forthwi�h oescxiaTpN �o,No. 11
cpmply with such provitions or Ihis permil sholl 6e d�emed ,��j� �-�} HWY.pqSi.WIDENING
revoked. BiocK iRACi ys}`+2� �T $TATE ENCROACHMEN7
LICENSED CONTRACTORS�ECLARA710N na.oF eincs. �ckMir No.
1 hereby affirm that I om licensed unde�prorisions of Chopter s�ZFo�iaT Noworato* C ,`Z
9 commmtin wiih Section 7000 of Division 3 of the Busi- �� � �p `x� �� �7
( 9 � 6UILDINGS A�$• ayqQ�s
ness and Profeasions Code,ond my ficense is in fulf force ond
effe�t. camancroR pari D1est & SOri IiSe. CONNEC710N CH4RGE F{F
LicenseNumber 37�y� Lic.Closs e t42 noocess 1494 Fiasuner AYB• �.1� Rc�.HeuaSemeNr Fee O i,
Contracror Yan Diest oate 8�3�/$7 caY Tt�NO UISTRKT NO. GROU� Mne vxoasseo sv v
BK PG Z
❑(am exempt under Sec. of fhe LA.Co. uCENse No. E)S] �CLaSs ri 2 � .C'� �- � '�,
Plum6ing Cade ond/or Sec. of the �� DESCRIPTIOh OF WORK r�e F�Nqi U ,
PUBLI[SEyyER�ONNECTINv TO DAiE ��s/� VqUDAT10N a
B.8 P.Cade for the following reason s�vr,�rwNK.s��nA�E ai oR Q� V
M15 ANplOff DFA!NFIE(p' F�NA� � Z
�0�8 HOV`.E SEWER CONNKTfkG TO BY
PRIVAiE�ISPOSAL 5 STEM
Signature CCLMMJECf ADUIilOhl4t&OG OR �
OWNER-BUILDER DECLARATION +Noa�c To House sevha
OVEFFIOW$EEPAGE PIT,�kAINFIEI�
1 hereby Pff��m ffiof{om exempt from ihe Contractor's License ExTN. CESSPOOI oerwEtl maNHptE
taw for the following reason(Secton 7031.5,Buisness ond Pro- � ntrea,cevwut prt peaNvpN HpUSE
�BSSiDRS COdB�: SEWER Of1�ISPOSAL SVSiEM
❑I,as owner of ihe properry,or my employees wifh woges as -��i�t1.C�
� their sole compensntion,will do the work and the s�r�cture
is not intended or offered for sole(SeUion 7044,Business �'• • • ' 1 G
and Professions Code). OWNER'S Permif s
❑I,as owner of the property,am exclusively canuacting with AUTIiORIZATION TOTAL FEE '2 Q � � �2�'��
IICClISEd COf1tIOCtOfS 10 COn3}IUCi 1I1B(]fO�C[f�SCCtIOfI�OA4, I HAVE AI THIS�AiE 0.CONiRACT WIiH THE HEFEIN NAMED CONTRACfOR 70 � � �^' T.
Bu5ine55 and PfD}ession5 CodeJ. CONNECT TNE ABOVE OESCRIBED E%ISTING UWELUNG 70 THF Pu9uC SEWER. L:•�L�V
CONSTRl1CTiON LENDING AGENCY � I�,C cJ_�-,,j
I he�eby affirm lhat rhere �s a wnstruc��on lending agency SIGNEDTHIS DAYOF tv_ �
for the performance of the work for which this permit is �NEF OR .
issued(Sec.3097,Civ.C.). o�NEpSA�ENt
r.00rzess
Lender's PWme
Lander's Address i
I tertify 1hN I have read this app�ication and sfate fRat�the � � �� � � �� i
above information is correcf.I agree to comply with ol�County I
ordinances and State laws regulating Plumbing and Sewers,
ond hereby authoiize represeniaiives of this Counry-to�enter i
upon ihe abo�e-m tioned poparry fw inspaction purposes.
� � �
Sigrwture , ermittee � Da e _ SEE REVENSE FOp E%PIANATORY�ANGUAGE
�m ,
�� v.!�o •�• , " ..
0
� � 4 Z+` �' 4 Gl A`��. �
T.�:i.� � .. V R� 0 Ol ?r
� ��C� ���N � �� �Py �� .� , .
.T�m �, •' m.�..,°' .w� O �E-. ��y ay�.n o a a.
. '. �.-�� 4 b"'N�M m � i � d N d �.`' �I"'�i x .+�i. C�. �
�����g dV� ��V.'� o p V,�, K,a�a.c y- . .
� o u o �/
N� ��. �� 7l. 'S:'.'�' 6 ti` �C7 n(} M 71 F N� �`r M
� �i o y� �+-a"a �c' •" M „�. w o��u�^�� , 'y Rs
�"� U �s'A''q''�" °' q,"1�.µ�� 'd Y'.'� `5 .: � ��., a�`¢''� (/% 4t
•�+`�' z,u�.v m d o a-`�-� z,�c�'. �' o o�c d t.'��x � ~'�.+
� �
,r� o ���°'��jod°� �= ..Q,�P`'" ��:�`„ �"c M �^ w
� M
V o.°' ��� x..°.,�";.6 .°a��v,,'L e' �F rt'°��:. � ��� �d v o
� « n y ,�o w es o o.4 ? � p, .M H
d �'CY U .rJ. p y` N`��� ��M M N� N�..�� Q � � OI
A �y',Q V w�i � ���'��` o J'.t Q "�+p � ei�� m'eS S.°'y v1 "yl V Q .
a, d 3 v� `k ��'N d r X � 0 K „ 7 �Rs` ��«�,.• '1� y, ✓ g
�� fi�► T',f�,��*V% oy'C 'g V�~0l C�� �n A • 0� � �
p :�;�'�n�-�3 t���';,,.°�a������ o ;��_;:� ,'� GZ
ra � d.d`p,`a',,�}, m ,+�"'P. d c�u � "c.�3 � � e�d�� ^pyy: �� (9
� ✓x✓ 4 a "'+w��' � �� ���d�' w w7a .�� �4.Q.4' �
� G.µ,°.�a �w �'°'�� �x�X e`"i �Q��•°.a. �m� o o c.
� �
� g'�-����odd°,��s~ d���,��� �
� � m.� a � �=;sm4s��, �
arl y 4."�� `,���,'�r'� L.y O �� ✓...
y y y„;y p � d 3 oQ, 1? w
T
�'y � x O 4 Y Q.�
O �.' (Ol•�.G�a'��' •�r....
����.'�
�� �
' �1,� t ``
.�
�� � \
Ny� � , �
1�� .+y ` � y�1\\ �},� e S` `\
G \ ` j � •
O ` `i • � �� �
� , �, , ` ,i\ ,t{ � y '
� �\ � � '�
� ! \ � t
Z ,`t 1 ! � '' r �� �� � `
F 4 `
t � \ � i
S , � �
5 `,�� � � �
� � � � � .
. . w
�; Q
; �, s.
N
?� O�+
a y
�� �
N
Z
�'q
0 0
o �
, � o —'
��, ���� ._,,-
� �
� ✓ � �� � �� ...:,,
r
� �, �o ��g �U� _
---~
O a ; �'� 4! G s.�
Y p � .,-
>o ,;, _ ... .
a'�i, `�Qo � ����"�1x ' ,_�._.
�
,yR ---
a � �i-o�i �' ��� $a _..
.�. �
� �m�a � _.,........_...-
'�.
���
,��
/...,