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HomeMy WebLinkAboutNo Permit Number (3) WORKERS'COMPENSATION�ECtARATION � I he�eby affirm that I hove a cenificote of consent to-selt �'�D%Y3/8] �I insure,or o cer�ifiwte of Workers'Compensation insurooce,or 76A��° � 1., o te�tified topy thereoF(Sec.3800,Lab C.� `E� APPLICATION FOR PERMIT Policy No. Company �� ❑Certified copy�s herehy furnished � � SEWER ` SEWAGE DfSPOSAL � �Cerrified copy is filed wi�h the county 6uiidin9 i�spection COUNTY OF LOS ANGELES BUILDING AND SAFETY deparrment ' �are 1 8 Appllcanr Yan Mest & Son, Ina. fOR APPLICANT TO FILL IN ��!('g`j CONNECTION DAFA CERTIFICATE OF EXEMPTION FROM WORKERS' eu�tun� � COMPENSATION INSURANCE - nooceu 20787 aiSS'E R7.7R fldTlB STATION � �C- cevrM . (This section nead not be complefed if the work involved by the ��A��i� M4NfKKE REFERENCE Q� � permit is fo*one hundred dollors($t00)or less.) � . . �NGTM FRan� �� . . .. r+��s� .. ... . . . _... .. . . -. . . _ -rvv�or�rvn�e �on I certify that in ihe performance of the uork for which�his CaD555T. Y. CURB .L. M.I.iOP.I. permif is issued,1 shaH not employ any person in ony manner � . so as to become so6'ect la the Workers'Com nsation Caws. � - '"��"O" � I � OwNER Q7.IMG.NO. K18N0. . . . �. NAIL . . � .. . . .. . �. ... .. .. ...:.._ .. . ._ . . �. .-...... �... -. ..�. . . . RDDRE55 .. . . . . � � iNlkW(PE4M1T NO:� R0.4D PERMIT NO. - Dote - Appticonf � . -. . . .. lUQTICE ip�APPEICANT: ff��after mcking�Nsis Certlf C01B Of uty , AFFI�AVIT WpIVER E15EMEM RECORO INSTit NO. DATE ._.. TE!NO.,. '. ' . ...... .. ' ... : Exemption; You �shuuid-6acome��wbjec�. to-t#re--Workers' . i�At . Compensotion provisions.of the.la6oacode,'yo�musi#orthwi�h o[scRirrrow ioTrvo. Hwv.oxST.wivervwc comply with s�ch pravisions o�this pa�mif shall be deemed /�./�o,A feVOkOC�. BLOCK TRACT T�V�'`� � STAiEENCROACNMENT LICENSED CONTRACTORS DEfLARATiON "1°.°F e`°°s. �RMiT No SIZE OF LO7 NpW ON l01 I hereby affirm ihot f om lltensed under prodrsions of GFapter � y 9(cQmmencing wi�h Section�7000)04 Bivision 3 of��he-B�sN euioiNcs Res. a��S � �ess and P�nfessions Code,and�my literne is irt i�l7 imte end effect. ZZL�1A. _ . e A,� � CONTN:eCrort j/y� j)j,est�Ec SD21 �IriC ��NECTIONCHARGEFEE Y ' v i j Eieense Number � � lie Closs Y . �l � ReimeuRsemENr Fee a � �+E�149 &�nes Ave A . t Comracror Yan Diest pQfe �f 1�87 �ismicT r+o. cuoua MAP CROCESSED BY V ? r CITY 7ELN0. .,, � � = i f ❑f am exemp�unda`Sec. of the t.A.Co. S¢ais�No. E)S� et�dss (�. 2 7 �. � � ; I Plumbing Code and/or Sec. of the NO. DESCR�7fI�N OF WORK FfE RNA�� JJ U � MOlISE YWER CONNECTING i0 DAiE � � � B.8 P.Code 4or Ihe followinq reoso� �&����^'ER � VAUDAYION � � SFFTIC 7ANK,SEEPAGE PIT OR FINAL 2 %TS AND�OR DRA'�NFIEI� � Da�e Hp(�$[WER CONNERING TO aY GRIV iE�ISPOSAL SYSTEM � $i9�p}UfE CONNECt AOpITIpNAL BILG.OR � OWNER-BUILDER DECCARATION M�OkK i0 HOUSE SEWER pVERFtOW SEEPAGE PIT,pRAINFIEIp I hereby affirm ihot 1 am exempt tiom the Controctor's License EXTN.CESSPOOL,ORYWEtI,MANHIXE Low for fhe following reason(Seclon 7031.5�BU�SR@55 Of�fl Pf0- AITER,REGAIR OR ABANOQN HpUY �.'�t?i�i F. � fE5510115 COCI@]: SEWER OR DI51'OSAL SVSTEM ❑I,ns owner of the property,or my employees wi�h wages as a' ' ' �� L• �heir sole compensation,will do the wwk and ibe structure �r, �i is not intended or oRered for sale(Section 7644,Business � � �2 r"�' and Professions Code). OWNER'S PermiT E ❑1,aa owner of the prope�ry,om exdusively controcting with AUTHORIIATION TOTAL FEE r ' ' '2 f'F�` licensed mntradors to construd she project(Seaion JOdd, I HAVE AT THI$DATE A CONTRACT WITH r�MEcew rum[o coHranaoa ro j�e�_A 7 6usiness and Professions Code). CONn+ea iNE neovE o[SCa�eEO ExiStiNG owEuwG ro rHe vusut sewea. CONSTRUCTION LENDING AGENCY � � hereby offirm Ihaf ihere is a construction lending agency SIGNEDTNIS DAVOF � 19_ for the perfarmw�ce of�fha work�for which this permit is owr�c ott OWNERS nGENT iuued(5ec.3097,Civ.C.). ADDRE55 Lender's Name lender's Address i I certify ihut I have raod ihis applica�ion ond stale thal ihe � a6ave information ie cwrect.I ogree to comply wi�h ail Couroy � � ordinances a�ul State lows reg�laiing P(umbing ond Seweis, � and hereby oufhorize representafives of ihis County lo�en�er � upan 9 above-m ifioned property for inspection purposes. Si a�Vre mitfee Da• � � SEE REVFNSE FOR E7(PIAHATORY IANGUNGE � � ,�n � tt m O� oe 71."' 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