HomeMy WebLinkAboutNo Permit Number �I WpRKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificata of consent �o self �-�2 ovw aie� 5"�
insure,or a certifimte of Workeri Compensafian Insurance,or ��6dZ0 LS
a cenified copy thereof(Sec.3800,Lab C.) "� .. . AppLICATtON FOR PERMIT
Policy No. � Company . . �t
❑Certified mpy is hereby.fumished. . . SEWER • SEWAGE DISPOSAL�
�Cernfied wpy is fiked w�th the counry build�ng i�spection COUNTY OP LOS ANGELES BUILDING ANP SAFETY
depnr men. � � �� � �
po,e B 1 8 APPi;�o,,, Yxtn Diest & Son, Z1sC. FOR APPLICANT TO Fllt IN 7fp CONNECTION DATA
� CERTIFICATE OF EXEMPTIOK FROM WORKERS'. - aunaruc srAnoN �� oevrH ��
COMPENSATtON If35URANCE nooz�ss �745 �St � �•
kThis seclion need not be comple�ed if tha work involved 6y the ,H4NNo�[keFeReNce �� °
permi�is for one hundred dollnrs(8100)or less.) tocAurv �ovr�R
MAREST � iYPEOf CONHEfi�ON — �[NGTM FROM
I certify tkwt in the performance of.the...work for which this �RO55 ST. Y. �UGB fl M.L.i0 P.l.
permit is issuad,I shnll not.emp)oy any person in any mpnner
so as�o became�s�6jech to the Workers'Compensa�ion Laws. �� � � co.v.w.rvo. ioe r�io�
- ��� TRUNK PERMIT NO. ROAD PERMIi NO.
Dote Applimnf ... A�E�
NOTICE i0 APPtICANT� If, after moking fhis Certifimta Of CI7V TEL.NO. AFfIOAVI� WAIVER FA$FMFNT kEIl�RD.INSTR.Np. DAIE
Exempfion, you shauld become subjeq ro the Workers' - ��A�
Compensation p/ovisioos of the Labor code,you mus�forthwith �F$CFIPTqN toiNo. �� Mwr.oa 5*.wiperrn�
cemply with such provisions ar this permit shqll be deemed
�gypk�, BLOCK TRAR 44824 �v SiAtE ENCROACHMENT
UCENSED CANTRACTORS DECWRATIDN �.�8LDG5. ffRMR NO.
S�ZE OF i01 NOW«t i�T C:,�/Y�.
I hereby offirm thal I am licensed under provisions of Chapter �a �J�Y�L q � Z
9(mmmencing wilh Section 7D00)of Division 3 of the Busi- s�ito�rv�s Res. CNARGES
, ness ond Professiona Code,and my ficense iz in full force and
� effect �parRacroa ji� Di.est & Son�,_♦Ine. fONNERION CNARGF FEE
License Number 376814 LIC.C�osS C 42 ADDRE55 t¢94 Hamner .Ave. j� i1 REIMBURSEMENT FEE O
COnitpCtM Y�L JJLBS Y �p�g l�/�1,U7 DISTRIR NO. GROVG MAP PR0�55ED BY V
(liY TEl.NO. BK PG z
❑I am exempr under Sec. of rhe LA.Ca i�Ns�No. G8S cidss (,' 2 � � Z �
P4umbin9 Cade and/or Sec. oF the �� DESCRIPTION OF WORK r�e F!vA� V
NOUSF SFWER CpNNECfING ttJ OATE � VAUDATION W
B.&P.Code for the following reason Pueut SEwEa __ �„ � �f� �
� SEGTIC�ANK,SEEPAGE GIT OR �NA� Z
PITS AN�/pR OGAINFIEL�
�iB HOUSF$EWFiCONNERlNG 70 BV �
PRIVATE DISPOSAL SYSTEM
$i9nQ1UI8 �ONNECi A[t01ilONAL 91LG.OR �
OWNER-BUILDER DECLARA710N WOFK TO HOU�SEWER
I hareby affirm�hot I am ezempt from the Controctor's[icense E�XTNF�CE55 EPWL oxvwe¢A�rt�nNMoie
Low for ihe foliowing reason(SCC10li TO3I.S,BUISliCSS dffd Pf0- Al1ER,REPAVR OR ABANO�N 110USE
� fg56iOn5Code�: SEWERORDi5PO5A15�5rFl�n
❑1,as owner of ihe properly,or my employees wilh wages as
iheir wle compansation,will do the work and the structure c�'��;,�}�:
is not intended or offered for sale(SeUion 7044,Husiness
and Prafessions Code). OWNER�S Permit a ,�. • � �� 1
❑I,as owner of the property,am extlusively contracting with AUTHORIZATION T�TAL FEE H• cr
licensed comradors to construct the projeci($ection 7044, t HAVE AT THIS DATE A CONTRACi YVtiH THE HEREIN NPMFD CONTRACTOR i0 � • �C f'`�`''
. BU51l12S5 QfICI PIOff5510n5 COdC�. �- CONNECt THE ABOVE DESCRIBED E%ISTING DWEtLING 10 THE P110LIC SEWER.
CON57RUCTION IENDING AGENCY � • • •L L�C�
I hare6y offi�m tFwt ihere is n construcfion lending agenty SIGNEDTHIS OAYOF 19_ �_V
for ihe performance of the work for which ihis permit is DwNEw oc � Q C„ �'.`]
� issued(Sec.3097,Civ.C.�. owNeRs n.weru*
ADORE55
lendar's Nama _
lender's Address
I certify.thot 1 have read this ppplimtion and state that the .
abo�e information is correct.1 agree to cvmply wiih oll County
ordirwnces and State laws regulating Plumbing and Sewers, �
and hereby auth irize representatives of this Caunty to enter
upon Ihe o6ave- en�i�ned pro erly for inspec�'on pu oses. - - - - � .
3�
Signalu Permiftee Do SEE kEVERSE FOi EXPIANATORY IANGUAGE
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