HomeMy WebLinkAboutNo Permit Number (5) , WORKERS'COMPENSAtION DEQARATION
I hereby affirm thar I have a certificate of consent m self vzmozovwsia� �
insura,or a certificota af Workers'Compensation Insurance,or ��b�ZD
a ce�tified copy rhereoi(Sec.3800,Lab C.) `�� APPLICATIQN FOR PERMlT
Poliq No. Company 0a . O
❑Certified copy is hereby furniahed. SEWEn • SEWAGE D15POSAL
�Certified<opy is f�led w�th the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
depart�F ery
oa�e 9/�/87 APP���a�� Yan Diest & Son, Inc. FOR APPLICANT TO Flll IN � CONNECTION DATA
. CERTIFICA7E OF EXEMPTtON FROM WORKERS'� aunoiNe STATION pEPTN 6
COMPENSATION INSURANCE noouess ?O 6 L2.$t RSID LII•
(7his settion need nol be completed if the work invalved by the ip�qiitv Di2�011d $8S M1WNFKKE REFERENCE I
permi�is for one hundred datlars�(;100)or lesa.) _ �owee
t�ARESi TYPE OF CONNECiION �ry�.TN FROM ��
I wrrify thar in the performanca.of the wock for which th�s c.�ossst, r. cuae P.L M.LTOV.L.
permit is issued,I shall not emplay any person in any manner
v.c.ruo.
ao as to ecome su iect to t e Wor ers'Compensation Laws. OWNER Co.Ilv�r,tio. �oa rvo. �j
��� TRUNKPE0.MITFq. qpADVERMITNO.
Date Applican� nooa¢55
NOTICE TO APPLICANT: If, ofter mokin ihi5 C8��1{ICO1C O{ AF610AVIT WANER EASEMENT RECORD.INS7R.NO. OATE
g CITY TEL.NO.
Ezempfion, you should berome subject �o the Workers' �Ai
Compenwtion provisions of the Labor wde,you must forthwith �escxiPrior� ior nro.� � Mvn.oa sr.wioEHiNc
comply with euch provi�ions or this permit shall be daemed pe� T
fBYOkBtI. BIOCK TRACf V 6L� l� STAtE ENCROACMMENT
LICENSED CONTRACTORS DECLARATION n+o.or azo�s. �RMir No.
1 heraby offirm thot I am licensed under provisions of Chapter ��orior npworv toT L
9(commencing with Section 7000)of.Division 3 of the Busi- g���5 � n /Z
Res. ouac,�s
ness and Professians Code,and my license is in fult force and
BffBC• CO�ITRACiOR �� Diest & Son I31C. coNHeaar�cNaRce Fee
license Number 376814 �IC,C��SS� p�Dp� 1494 Fiamner Ave � � REIMBVFSEMENT FEE a
9/ / 7 �
�ISTBICT Np GROUP MqP PROCESSEP BY
Comroc�or v�Ti D e8 Onte j $ cttv rei.rm. V
7 BK PG
0 I am ezempt under Sec. of the LA.Co. Ac Nse No. G8'I ��cyass L+ 2 !� ��j � p
�: � DESCRIPfIONOF WORK FfE ~
. P�umbing Code and/or Sec. of the FiNAi U
HDUSE SEWER CONNECTING TO 1 • oAre VALl�ATION y
B.8 P.Code for ibe following reason P�B���YWER �(Q G
SEPfIC TANK,$EEGAGE RT OR � N
DO�E PITS AN�'OR DRA:NFIEi� FINAL �
HDUSE SEwER COn�wF[iiNG i0 BY �
CRIYATE�ISPOSAL SVSTE '�
S�91IOtVfB WNNECf AOOITIONAL&DG.OR � '�
� OWNER-BUI�DER DECLARATION � woeK To Nouse SEwe� - '�,
�VERFIOW SEEPAGE DIT,CRAINFIElO I
I hereby offirm thal 1 am ezempt from the Con�roctor's license extN.,cessroo�,oerweu,rnnNHoie
Law for the following reason(S@CtOfi 7O3I.S,BUISOE4S tlR(I Prp- AITER.RFVAIR OR ABANOIXJ Mq15E
fQ5610f15 COfIC�: SEWER OR�ISP.75A1 SYSTEM ''�
❑I,os owner of the property,or my employees with waqes as `C�n��' I
their sole compe�sation,will do the work and the structure �� � � � .) �,
is not Intendad or offered for sole(Section 7044,Businew
and Professions Code). OWNER'S Permit 5 'JQ Q I • •C�•J�C
❑I,as owner of tha property,am exclusi�ely cantracting with AUTHORIZATION TOTAL FEE 2 Q
IiC805BCI COfIff4C�Of5 10 COfIShUcf}he Pfo�eCl(Se[tiOn 7044, 1 HAYE A1 iM15�ATE p CUNTRACT WITH THE HEREIN NAME�CDNiRAQOR f0 •' ���,5 U u �
gUSillB$4 OII(I PIO{035i0119 CO(IC�. CONNECT TME ABOVE OESGRIBEO E%ISTiNG DWEILING TO THF PVBIIC$EWER.
. WNSTkUCTION LENDING AGENCY � �(�l O 5—E'] I
1 hereby affirm that fhere is a construction lending ogency SIGNEDTHIS DAVOF 19_ �
for Ihe performonce of fhe work for which this permit is a'``�"ER� �
issued(Sec.3097�Civ.C.�. OWNERSAGENT i
aooaess
" Leoder's Name
�� Leodei s Address
_ I certify thot I have read this applimtion and state�hat the
. obove information is wrrect.I agree to comply with ell County
ordinances ond Sfofe laws regulating.Plumbing and Sewe�s, ��
and hereby author�e represenfotives of this County to enter
uppn the qbove- tioned prop rry fw inspe tion p ppses,
Signafur ermittee � te��� SEERfVfRSEFOREXPLANAiORYLANGUAGF
�
' �
' 4 v1�ti Ol O N C1 d �' ?1-���.' 7�t." � �� �n O�O� ap
�ire1 � ��w p+d+y�CQ�'�m "' � V y'� �� C L �
-�.. �s O y`'�., tl� � k �y 4 X d o � � y� �
� L.�,•:c +�i sa�i M .�o, r o O eC ��'1'^ � � ?� � . .
'-, � e p h �U ` � � B�H o � 4 G m m
E~ v° �.=" �` � d ""tiw d � �t' o,' *�wQ
� a, � w'� o � � �;��t d a o '� w 01 ° e�.� b a
r °i � o a � ° ». k n � o 0 0 o X ;
�;� a d �, �. .,
. �. Q�' C X�ia��L'!! z;Q w m 4 w ^a �n,��°.,�0�y�,� � .
U `�+ ��i ,� �� `�' Oi °'4 G C c V w M �m �� '"' G '' • '
/� C� �n ti "' O��i•;;\��".. ?i C «" ry '�" q V`.�,._' ��T ' '
Fi E BC'C! y :t C�::a O W d d.�.. y M y�;�0 a ti p Cv, 1. .`! ., CJ a ..
j G Q V`'�M�0�y ,�" iL� F i: pb�' y�. QJ f�r�
WL �C7 � `I *+'`l O `j '�!�+�10.�C Q� m'!S'.°�. �+ � PJ �
� � a � � � L � �F �p a� � �� ~ �. � o ~ �
�� �� " �-c� n� �`�..iCoda'� o $ m �e � q,� a+
w.l w°°` �'.^. « .�'.. �o::^�;�x :: b��w €o�' y:tl 'b �
� ���p �.� �+�.U�.?"e t e � �{, C � � o"��,� �p �� i�7 +�+
«
GQ C tl tS d � pi•• � O �++� Y/ � It � c� i. �'Q F+ Ir
E �a � ��:~:;.. � a•� d � �,ts .CL o
([��7 ��Q'.� � " d� �3a'ti o�i�b 3 w � �w $ °' 'a� a m •E�i "" -
� �' 4 p( p �C� R Vi O �•y� •� +. .,.�.,tl , .
p,°��.O+� � ��z n n O��.� O�f,j�•a� O � �py� . y, U �
y"a y L�c o,3 � c M � a '� y �o wY Q ` -° a
Q y � hy'o ��_� � k.�,,°z�� a��� � � o���am-_� p'� � �
�.c
�ti 01 x ��, � � A
'C $ � o �'., mo;�+m � 0,0.� �� £
~•.�W 3b ef �tY�a1« � Mt�❑�h� 0.w na E o a
�
F
O -
Z �
� �O
� . I
s `
� 1 �� ; �
— ; i � � 4 � i � � �, { � I
' � � � � I � ; � f ; �
i � � ; � j � F I �
i � i � � � i � j �
I ; J � i
� � I j . ; � ...� � 'I ( I �
I � � � I � � � � �� �� � � ; � ' �
� � i I : �
� � ,
4
2
� ,
N
N
� � .
N �
Z _ � � i
a Z i
O M
i---- O �
i V
E � � y f
y Z �
Q � ❑S�n
N
� ZY S � �N <� Z W
O
O '� Oo W�' �Q c�y� g V
� � n3 "'¢i ai� �, up .
� � s� Qo Q Wa G� �N
� � �W �
= G „� � � a
� 8� �� � �� �� �` I
� � s< ��