HomeMy WebLinkAboutNo Permit Number (5) . � WORKERS'COMPENSATION DECLARATION .
: I bereby offirm tha� 1 have a certificate ot consent ro self �'��OWI3/B] �
' insure,or a certificate of Worken'Compensation Insumnce,or ��eno
' a cenified copy thereof(Sec 3800,Lob C.) "� APPLICATfON FOR PERMIT
' Policy No. � Company� � - �s
. ❑Certified capy is hew6y furnished, � SEWER - SEWAGE DISPOSAL
�Certified copy is filed with the couMy building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
.{ deP�rt e t. . - . ._ .._
1 oa�e � 8T Appficant v� �iest & Son� Inc. ppR APPLfGANT TO FILL IN 5'�- 5' CQNNECTION�ATA
_ _ . _
` CERTIFICATE OF EXEMPTION FROM WORKERS' � auxw�+c
� � COMPENSATION INSURANCE� noouess ZO7�7 �a''2.St Rlm LA• siaiioN � cevrN�j
i (This seUinn nead not be complelad.kf�he work involved by the Dlc�pnd ,82� m,wr�o�e xeFeRENce / ��R"
. permit is for one hundred dollon.($100)or less.J, �_ 1O�°'r - towett
1 certify 1ho1 in tha performance of ihe wark for which ihis �A�ST tvaEOF WNNECriOrd �ENGiN FaOu C�
C405S ST. V. CURB .� M.t.TO P.l �J
permit is issued,I sha14 not employ any person in ony monner
so os to beeome su6ject�fo ihe Workari-Compensation'Laws. owrvea m.una.nq. %d No. L�
� � � � � ��� TRIINK PERMI7 NO. FOA�PERMIT NO.
Dare App�icont A°°�u
NOTICE TO APPLICANi: If,.after making this.�Cerfificate Of GTy TEL.NO- �FIDAVIT WAIVEi EAYNFNT RKOII�.INSTk.Np. DATE
Exemprion, you should become su6jecr to r6e Workers' iE�Ai
Compenwtion provisions of the labor eade,yau must fonhwith oescRieria+ toT rao. 8 HWV.OR ST,WIDENING
comply with wch provisions w this permi�sholl.be deemad 44$�4 �v
f@VOI(Cd. BIOCK TRACT SiATEENCROACMMENT
LICENSED CONTRACTORS DECIARATION �.�BlDGS. PEkM�T NO.
I bereby affirm that I am licensed under proaisions of Chapter siz[or�or nowoHioT � 3/ 5(!�Z
u5E Of E� �/
9(commencing with Section 7000}of Division 3 of�he Busi- auiiowGS RS. CHnaGeS
ness ond Profenions Code,and my license is in full force and
effed. ca�rp�ap� �g� � C CONNECT�ON CHARGE FEE
LicenseNumber 768�4 LicCiass r. 42 zeimsuRsen+enrvEe }
� Q �oR�1 FIamner Ave ' � a
�Ol1hOC10� van Diest Dp1e J/�'8� ��TY N��'� TE�Pq 73(��`r�A 2 DiSiRICT NO. GROUG MAP P170CESSEO BY V
`tY
� BK PG Z
❑I am exempt under Set. of rhe L.A.Co. ucErase tio. b$'� cioss �� Z �
f-
Plumbing Code and/or Sec. of the �- DESCRIPTION OF WORK r�e F�NA! � V
Nouse sewee oowaernnm To oare �F VALIDATION �
6.8 P.Code for the following reason R1BI.K SEWER a
SEPTIC TAPIK,SEEGP:GE PfT OR FINAI ?
Dote P!TS AN�iOR CR0.INFIEtO q
FK3USE SEW4R CONNECTING i0 BY �/"
PIiIVAiE�ISPOSAI YSiEM
� Signature CONNECT AODIiIONAL 8tIX'i.OR �
OWNER-BUILDER DECLARATION �K T°�us�s�u�2
OVEfiFLOW SEE�AGE vIT,04AINFIEtD
I hereby affirm ihaf I am exempt fmm the Cnntractor's License EXTN_CESSPOOI,ORYWELL.MANHOLE
Law for(he following reason(Secfon 7031.5,Buisnass and Pr0- AL7ER,REPAiR OR A&ANDON HOUSE �a G�,.j�y
�OSSIOM1�COdO�: SEWER OR DISPOSAL SVS7EM
❑I,as owner ot iha properfy,or my employees with woges as �+� • • • � L
their sole compenwtion,will do the work and the structure
is rtot imended or affered for safe(Seciion 7044,Business permiT g � • •�i,�C�
and Professions Code). O W NER'S
❑I,as owner of the property,am exdusively comrad�ng with AUTHORIZATION TOTAL FEE •• •C t,�G�S
. licensed contrac�on ro construU the prQjed�Section 7044, i Hnve nr THis onre n mHrancr wirH�HE N[eein n�nnneo mNrxncroa To /'�/� p )
BUSinBss and ProIeS5iOn5 COCIE�. CONNECT TME ABOVE DESCRIbE�E%�SiING DWELLING TO iHE PUBLIC SEWER. � U li 5—V I
- CONSTRUCTION LENDING AGENCY �
I hereby affirm that fhere is a conslruciion (ending agency SIGNE�THIS DAYOF 19_
- for the performance of the work for wh�ch �his permit is own�ie4s�nceNr
issued�Sec.3097,Civ.C.}. �
noo�ss
tender'a Name .
Lender's Address �
I cerlify fhal 1 heve read ihis applicolion and state thnt fhe
obove information is corretf.I agree io compfy with alt County. . ,. ,..,
wdinances ond State laws regulating Plumbin9 and Sewers.
' and hereby authorize representarives of�his Counry ro en�x
upon the a6ove-m ntioned prope�ly fw inspeclion pu�poses. � � � � ����� � � � "� �"���� �
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. Signolu�s ermiHee Daf� SEE REVERSF FOR EXYlANA70RY IANGUAGE
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