HomeMy WebLinkAboutNo Permit Number (3) WORKERS'COMPENSATION DECLARATION
I here6y affirm ihat I 6ove a terlificate of consant to salf ���DPW 3/8] • �
insure,or o certifitate of Workeri Compensation Insurance,or �6�1°'1°
a ceriified copy tliereof(Sec.3800,Lab C.) C808 APPLiCATtON FOR PERMIT
Polity No. Company - �• -
❑Certified copy Is hereby f�rnished. SEWER - SEWAGE DISPOSA!
�Certified copy is filed with ihe county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
deparjmg�t.
Dare 9/�/87 Applicont Dan �jeet & 5017� �,I1C. ppR APPLICANT TO FI4L IN � CONNECTION DATA
_ . _.. . .
�CERTIFICAif OF EXEMPT{ON PROM WORKERS'�� � ewioiNc �7 — /
�COMPENSNTION INSURANCE�� �� nooaess 2�71�l �St �lm ��Tle srnTiorr 3 �' o[vrH
(This section need not 6e completed if�he work involyed by the i�iiT� MANHOLE REFERENCE � °P�E
permit is for one hundred dollars($100�or Iesi� TYV"c OF CONNELTIpN
' hEAREST IENGTH FROM n
I certify thar in the performance of rhe work for wh�ch ihis cxoss n. v. cues i. M.�.to v.E. L�
permit is issued,t ahol�not employ ony person in ony monner — p�� /�/^
so as ro become aubjeu to�he Workers'Compenwtion.i.aws. o�ER � pn CO.IMP.NO. J06 NO. (f���
��- � � ��� TRUNKPEqMITNO. ROAOVERMIiNp.
Date Applicant ADORE55
AFFIDqVR WAIVER EASFMENi RECORD.INSTk.NO, DAiE
NOTICE TO APPLICANF: Ff,:_afler making.)hiS.,Cactifitofa of �Tv TEL.NO.
Esemption, yo� should�become subject to the Wwkers' �GA�
Compensation prmisions of�he la6or toda,you musi fortbwith cescuivirorv tor rao. 5 HWY.OR ST.WI�EN�NG
comply with wch provisions or thiz permit slwll be deemed �8�4 I�
revoked. siocK TRACT STATEENCROACMMENT
tI�ENSED CONTRACTORS DEUARATlON� - � r�.o�ai°�s. v�Rmir r�c.
I here6y affirm ihat I am licensed under provision;.of Chapter ���o* niow or+tot a .
Rea. ' �"
G(commencing wiih Section 7000j�of Division�3 of the Busi- auiio�n�s c++Aeces ,
nesa end�rofe�eioru Code,and my license is in full force and I.
effecr. 68,� `, 2 mr+TaAcrorz va,n Diest & Son I32C. coHrxc*�a+cNcxceree �,
ficense N�mber 37 4 Lic.CIasS 4 n.�pRFff 14g¢ Hamner Av�L� A aeiMeuas�MeNr Fee a ��
9� , 7 �ISTRICi NO GROUP MAG PROCESSED BY O
co�r.o«o�Yan Diest �,e 1 8 f cm re�No v '
BK oG Z
❑t am enempl under Sec. of rhe LA.Co. S�Ns�ra. GB� ciAss �i 2 �� �.J � � � �
Plumbin Code and/or Sec. of�he �� DESCRIPTION OF WORK �e FlNA1 V S
9 lqUSE SEWER CONNECTING TO D4?E / /�� YALlDAT{ON y
PUBtIC.SF'MER
B.8 P.Code for the following reason � /��TL� � al
$EPi1C TANK,$EEPAGE PIT OR GINAL ?
pp e PITS AM�-OR DRAINGIEID
' iK1U5E SEwER CONNECTING TO' BY
PRIVATE OISPOSAL SYSiEM
S19fI4fUl2 CONNECT AU�IiIONAI BI�G.OR �
OWNER-BUItDER DECl/�RATION ID'ORK TO HOUY SEWCR
OVERFIOW SEFVAGE G�t,DRAINfIEI�
I hereby offirm that I am exemp�from the Contracror's License [xrN.,cessroot.oavweu.+.wNHO�t
Law for the following reason�Secton 7031.5�BUiSnC55 OlIfI P!O- Al1ER,REPAlR OR AOANppN FIIXISE ^
{BSSIOFlS COdOJ: . SFM�ER OR DISPOSAL SVS7EM �t/�'U U A
❑I,as owner of 1he property,or my employees with wages os - {}+ u r a � v
their sole compensation,will do the work and rhe slrutlure
is not imanded or offered for sale�Sectian 7044,B�siness � •���
andPrafessionsCode). OWNER'S Permit S 10• 5� c ."v'
❑I,as owner of the property,om ezclosively cororacting with AUTHORIZATION TOTAL FEE • • ��1�5(;'�
Hcensed mntrocton to construct the projeU(Section JO44, �HAVF PT THIS OAiF A CONiqACT WI7H iHE HEREIN NM1ED CONTRACIQR TO
BUSIlM55�4lld WOfCS510I15 COCI9]. � - CONWER iME ABOVE�ESCRIBE�E%ISiING OWCI[ING i0 THE RIBLIC SEWEM_ - + O,V F�£` /
CONSTRUCTION LENDING AGENCY . �
I hereby affirm that ihere is a construction lending ogency SIGNEDiH15 DAVOF �4_
for the perfwmance of ihe work fo. which this permii is own�ieus�aceNr
iasued(Sec.3�97,Civ.C.�.
ADDRE55
Lender's Name
Lender's Address- �
I cerlify that I have reod this opplicotion ond state ihat ihe .
obove information is correc�.I pgree to comply with all Coun�y
ordinances and Stota lows regulotinq Plum6ing ond Sewers,
and heraby aoihorize-representatives of this County�a enter
upon fhe obove- tioned prope fy for inspedion purposes.
Si noture ermittee Dof� I SEE REVEKE FOR EXPIANATORY IANGUACF
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