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- _..__..'--'- __ __..}.
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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 �
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