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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. 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