HomeMy WebLinkAboutNo Permit Number (5) 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
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