HomeMy WebLinkAboutNo Permit Number WORKERS'COMPENSATION DECLARATION
1 hereby affirm that I hwe a certificate af consent to self 9Y-OOOP DFW 3/B] � ',
insure,ar a certificate of Workers'Compensation Inwrance,or �°A6�zD ��,
a certified mpy thereot(Sec.3600,Lab C.J `E� � -� APPLICATION FOR PERMiT
Poliry No. Company - �s �
❑Cerfified copy;5 he�abY r�.,,,�h�. . SEWER - SEWAGE DiSPOSAL
�.Certified copy is filed wi+h rhe county build�ng inspection COUNTY OF LOS ANGELES BUIIDING AND SAFETY
deportment.
Date 1 8 Applicont �� Diest & Son� II1C• FOR APPLICANT TO Flll IN f�(S CONNECTION DATA
CERTIFICATE OF EXEMVTION fROM WORKERS' � g�iipi�
COMPENSAiION INSURANCE ADORE55 F � �Ip j,�y srariori J71-7 oecrH /
(This settion need not be completed if�he work involved by the � - � ��li�mpnd B2�- � � hw��aE REFEpEr�tE z y �� � ����-� � uroea� �-
permit is for one hundred doI(ors�S700j ot lesg.) ,. �� � ��A�m � �
. ... . NEARESi TYVE OF CANNECTtpN �ryGiH FROM �C .:
I cer�ify�ha( in ihe perform.ance of.(he work,for whish�his CROSS ST. ' Y. CURB P. � M.l.TO P.l. ly�
permit is issued,I sholt.not employ ony persan in eny.manner . . . . . . . . .... .:..
so as ro become sv6'ecf tv the Workers`Com ensotion Caws. wp2�{�►OII P���NO�
E p � OWNER CO.IMP.NO. Jpe NO. /d
. . . .. .... ...: . AA4IL TRUNK oERMIT NO. FOAD PERMI7 NO.
Date Applicanf . �.... .. ��. nooaess �
NOTICE TO APPLtCANT� If, ofrer�making �fiis Gertificate of p�r TE�.No. nFrionvrt wArvEa cns�mcNr wEcoco.irvsm.rvo onTe
Ezemption, you shauld-.6ecame-sub�ect� ta�-:ihe.-Wackers' ��a�.. .
Compensarion provisio'n of the ln6oc cade,you muss 4orthwith oEs[aivriar� ioT No.
[omply with such provisions or this permit.shall.6e deemed p �Y.OR ST.WIDENING
�i lOYOIICd.. . .... _. .. '__._ _ .."—_. . ... ._.__-. BLOCK iRACT OZ IV pEAMIT Np,OACHMENT
LICENSEO CONTRACTORS DECIAft,AT1QN. "����5� J
.� - - sizc��o� raw on�oi
� I hereby oHvm�hot I am licensed uadar pro��s�onc of�Lfwpter �� �' � �
9(commenang with Section 70003 of Divisifln 3 of ihe HUSi- BUIIOINGS aARces
ness and professiorts Cade,and my license is in full force and
@NBCI. C0�11RAGTIXt an Diest & Son Ine. ��NE�T��.,�NA��ee -
�p �3Yz�4 o7 Sr,��,,� /, '
Licence Number 81 tic,Gass . r+ �12.. nooaEss 1 S]GYLi3eT LIYE A _ REIMBUBSEMENT fEE a �i
CoMIGGiOf r� L+eSt DatE ���/V` CITY TEl.NO. DISTRICTIdO GROUP µ4P FROCESSEOBY V �,
BK PG Z
�1 am ezemph under Sec. of the L.A.Co. �IceNSE No_ 'C)H� ttnss (�. 2 � �J � p �
NO. . OESCRIPSIONOf WORK rEE � ~ �
Plumb�ng Code and/or Sec. of the Fwai U
HOUSE SEwEG G�NNEC7ING TO DATF W I
8.8 P.Code for�he fo�lowing reason � cueuc sewea ��r ,� VALIDATION y il
SEPTIC 1AN1(,SEEGAGE%T OR fINAI, Z �
P�TS AND�OR�AwFlEt�
Date MpUSE SEWER CONNEC7ING f0 BY —
PRIVATE�!SPOSAL SYS7EM
SiynpfUfO CONNECT ADD1110NA1 BLDG.OR �
OWNER-BUILDER DEQARAT�ON woeK ro Hous�sewea
�� OYERFLOVVSEEPAGE W.i,DRAINfHLO
I hereby afiirm Ihot 1 am exempt from the Comractor i ticense esrN. ceuroa oarw¢u.nuNrwie
tbw fOr the foliowing reoson(Secron 7031.5,Buisness and Pro- xiea,aev.4�a ai Asr.NooN HOuse .���,�.'� �
S958t�f15 COC�B�: SEWER Olt�ISPOS4l SYSiEM
❑I,as.owner of the properry,or my employees with wages as t�� � • • ! �i
their sole compensation,wi�l do fhe work and lhe strudure
is not iNended or offered for sale(Section 7044,Business Permit s � " •L l..�'i(�,
and Professions Code). OWNER'S _
t ❑I,os owner of the property,am exdusively contracting with AUTHORIZATION TOTAL FEE 2 � ° � ���'��`-'
� licensed contractors to cansiruci the ro ect Section 7044, ' /� q
P I � 1 MAVE AT iH15 DA7E'A CONiRACT WITM THE HEREIN NA,NE�CONiRAC70R TO I O.i/��—C.7
BUSInE55 and PfOf855tOn5 COdEJ. CON�NER THE ABOVE OESCNfBF�EX!cT�NG�WELLING TO THE PU9tIC SEWEN.
CONSTRUCT�ON LENDING AGENCY �
! I hereby affirm that there is a construction lending pgency SIGNE�THIS �AY�F 19_
for the rformonte of the work for which ihis rmit is OWNEG OR
t � � OWNERSAGENT
issued(Sea 3097,Civ.C.). .
aooaess
Lender's Name
lender's Address � �
I certify that 1 hove read this application and state that the
above informption is wrrecr.1 ogree�o compty with oll Coumy
ordinances and State laws regulating Plumbing and Sewers,
and hereby a�thori �epresentalives of ihis Counfy to ente�
�r upon t e above-m tbned properr fw inspe tion pu poses.
, 3�
_� Sigo re o �mittee e SEE REVFQSE i0Y EXiIANAiOAY LANGUAGE
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