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HomeMy WebLinkAboutNo Permit Number (3) WORKERS'COMPENSATION DEGLARATION 91A004 DPW 3/B] . � ' II I hereby offirm that I have a certificate ot wnsent to self �eaaazo �4 insura,or a certifimte of Worke�i Compeowtion Insurance,or �t�8 o certified copy thereof(Sec.3800,lob C.) APPLICATION FOR PERMIT °o11j'"° c°"'P°"'' �` SEWER - SEWAGE DISPOSAL ❑Certified copy is hereby furnished. �Certi4�ed copy is filad wi�h the counry building inspection COUN7Y OF LOS ANGELES BVIlO1NG AN�SAFETY depprimenl. pate $ 1 8 qpp���a�r Pan Diest dc Son, IT1�► iOR APPLICANT TO FILL►N CONNECTION DATA CERTIFIC'ATE Of EXFMPTION FROM 4YORKERS' • � ewiar�c surior+ �RTM COMPENSATION INSURANCE AD�RE55 ZEJ751 E36'C R3.ID Tdl• lJ � (This section need not be completed if the work involved by the� � � rNwNpwReceaeracE � � - u�R iouutv permil is for one hundred dollars(5100)or Iess.J �. - tYPEpF[ONNERION IENGTHFROM � C, NEAftE57 1 certify that in the performance of the work for which this C40554. Y. CURB .1. µ��•T�P��� ��`� permit is issued,I shpll not employ ony penon in any manner � P.C.NO. /�7 w os ro bewma subject ro the Workers'Compensation Laws. � OWNER - CO.IMP.NtJ. JOB NO. �!J MAIL TRUNKPEFMIThq. RW�DFFRMITNO. �01@ APPIICOnf � A�ORFu AFfIDAVIi WAiVER EPSEMEM RECOQD.INSIY.NO. DATE NOTICf i0 APPLICANT: if, aher moking this Certificate of �iTY re�.No. � Exemption, you should bemme subject ro the Workers' i�� Compen:ation provisions of the Labor code,you must forthwith nesce�rnon tor rp. Hwv.oa sr.wioeNirvc comply with such previsions or this permit shull be deemed /�p^ reYOkEE. ' BLOCK iRACf `Yi�L4 � AAtEENCROACHMENf LICENSED CONTRACTORS DECIARATfON rvo.cx aio�s. °ERM�'nro. � sac or ior r�ow ow wr ��/ �y� 1 heraby affirm Ihat 1 am licensed under prorisions of Chopter _ ��pp 9(commencing wi�h SecF�on 7000j of Division 3 of tha BUsi- RV4D�NG5 R8S• _ ���E� � nass ond Pro4esaians Code,and my litense is i�full for�e ar:d � -.�-- . - -��"� effect.. � . . . .,. .- .,.. .�• ...:..., .-._.,. eor+retci�enar�rE¢�- . _. � ^ coreruncrea- _..__..'--'- __ __..}. ,... . _. --- --- c, Zry ----- ---- -------- ��ICBfl66NURlblf.'_ 1f�S1Q- CSC:�IQSG—��—_."'_"__....._.._ "—".— ...._ �....___`—'__ REIMB�RSEMENTFEE �. ADDRE55 � ��S �VB A �/ O ��(11fOCiOf Yau Diest DO�B 8/��,�� �)7y ���� �El.NO 734�+�� �ISTRICENO. GROUP N.4G PROCESSEDOV (J BN PG � Z S7ATE � iK,. _ �`r...-. .� � . . _.-. ¢ '�, 0 I am exempt under Sea . _. of�he�,A.Co. . . �K€N�yp.�.. :_. _..._ . c�,tss. -- ..- - �.. Plum6ingCodeand/ar5ec. otthe "'O� ^ "oescaiPTloNOP�woeK - rfe � -� ---� � � �� � � O_ .. FI'JAI. ... HOUSE SEWFF CONNE'"fING T0 j� �,_ �are,: . _ --- _ ---VAIIL?ATIQM.• .-a .� �._ � __._ .__ rueiKsexta � --- ---__ _ _ _ �.cY ��7�.._ : B.�&R�Codetorthefollow7n roason�' .�. . .- .. -. .. . ... � . ....._ � ... ..�..., .�- SEPT�CipNK.SecPAVER70% .... ..' ..�. . Z ..... .. � F NAL . � _. : Dote � �� '� virs M�o.OG OR�N.._D ...,.. g{..,.... �/j if /.r� -/ : . _ � ..,... i .� � 1qU5E SFWf4[OMhK[�1!J,r7 '.•.^'._� •.' .�• ,•...••_.' •• ._ `/� . . . � � � �-' - ' ' "� � �.���� �� PRIYAIEDISPOSNSYSiEM $19natUre CONNECT A�uITIONnI&W.Ok � 6WNER-BU�lDERDECLARATION '''' �+F�oHous�s�w[a CNEflFIOW SEtPAGE PIT.DRAINfIELD 1 hereby affirm that I om eaempi from the Convactor's Litense earN..cessvoot,oaw+eu.rowNHote �� Low for the followirtg reason(Secron 703L5,Buisness ond Pro- rarca,r�vniv ok aenraooN rroust �C��4 p �e5810111 COdff�: SFNER OR DISNOSAL SYSiEM � �]�,os owner of�he properry,or my employees with woges as rt• � •• 1 � . Iheir sOle compensotion,will do ing wwk nnd fhe s�ruclure is not intended or offered for sale(Section 7044,Business OWNER�$ Permif b ��• � � • •2!�5 G ond Profeasions Code). ,� ❑I,as owner of the property,am exdusively convoct�ng with AUTHORIZATION tOTAL FEE �1• •• �2 7�.`)Ci v licensed controctors to corotr�ct fhe projen(Section 70a4, �F{,qyE AT THIS�A1E A CONiRACT WITH THE HEREIN NMMEO CON�RACKNt TO BU8111�53 and Pf0{'BSsiOn3 COdO�. CONNECT TNE ABOVE�EXRiBE�E%ISiI1JG DWEILING TO iHE PUBLiC SEwER. '�O j��" CONSTRUCTION LENDING AGENCY , � � i hereby affirm that there is a consiru�tion lending agency SIGtJEDSHIS DAYOF �9_ for the performance of the work for which ihis permit is p�,y�p�nceNT � � � issued(Sec.3097.Civ.C.). . . F� AOORE55 � . �lender"s Name Lender's Address � certify Ibat I have read this opplimtion and stote ihot the above information is corracf.I agree fo comply with pll County ordi�ances and Stote laws regula�ing Plumbing and Sewers, � and hereby ouihoriz reprasaMotives of this CouMy to enter _ upon the above-me �oned propeN fw inspecfi n purp ses. � SignaNre rmitlee Dot � SEE REVERLF FOR F%PLANA70RY IANGUAGE � m ���+MO y.0 . � �� o � �� F �.•cq a � a � m 4�«c�p.E��.�n� � C� v o � �, T`fl"�-, . .M� N� M 4 F.�i � � '� �'S�' �h, ? y ^ . ' '°„� a ",r «`�-�" �,i. c 'fi o 3 e � c.e ° , b''"' 3 i tl V=.«�° d o � � � ei E-� �ct �,,o o �. �i�^ 0 4.� O «S tn '.' F �. 6i u c� n n�,s` � °' _ � m O V �'.�� �U � � p��� O a o Y o U_�«�::. O_ 00�"ti'�• Y.' aO � x �C ~''Uv ..�.'4 �i°..' :S... p " 1 � . t� (J�'. yT.��. +Ctl � � , 2 � G•�.. .^'ri 4+ � m C� ,R.3.; '. 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