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HomeMy WebLinkAboutNo Permit Number WORKERS'COMPENSATION DECIARATION � � I hereby offirm thot 1 hove a certifimte of consent to self 9&000P DPW�/87 ^ � insure,or o certifimte of Workers'Compensation lnsurance,or 76�4�� �� acer�ifiedcopy�hereof(Sec.3B00,1a6C.) `E� APPf.ICATIQN F�R PERMIT 1S - Policy No. ComDany ms _ - ❑Certified mpy is hereby furnished. , SEWER - SEWAGE DISPOSA! �Certified mpy is filed wtth'rhe munty 6uilding inspection COUNTY OF LOS ANGELES BU�LDING AND SAFETY depar m nt. � � � Do+e 9��,87 ApP���Q�� Yan Diest & Son, Enc� FQR APPLtCANT TO Flll IN f f- CQNNECTION OA7A CERTtFICJaTE OF EXEMPTION FROM WORKERS' � ���oi� T,. - � _ COMPENSATION INSURANCE A�REu �20793 2-'638� R].N .i,y{� STATION rL oevrN (This sectian need not be compieted if the work involved by fhe ��i�iy D12mOT1(� B2Z N.4NHIXE f7EFERENCE � � permit is for one hundred dotiors�$i00)or less.) .. �owex � I certify�ho�in the performance of the work for which th�s C�Sgr, �� � - ���� Tvreorconinieaiori ��THF4pM � permit is issued,1 shotl no!empfoy ony pe/eon irt ony monner t,r,,,T'' �. CURB P.L M.L i0 P.L - so as to bemme subjea to the Workers'Compensation Laws. �Ep ��+y�� m.iMv_No. �oe No, uan : pore Applicant nooc[ss TRUNK PFRMIT NO. ROA�PERMtT NO. NQTIC€ FO APPLICANT: If,�ofter mokin this.Certifimte of nFFionvit wnivea ens�rnENT RECORD.INSTR.NO. DATE 9 clTr iEL.NO. Exemption, you should 6erome�sobjetl �o fbe Workers ��� � Compenw4ion provisions of�the Ln6or code,you must fpihwith o[Scrrivrion toi r�o. Q Hwv_oR sr.wio[N�NG comply with such provisions or this permir shall be deemed ^�p�,{ �� revoked. eiocK iRACf '}�o�'{ TY S1ATE ENCROACHMENi � r+�_a e:ocs. ffeMn r�o GCENSED CONTRACTORS DECLARATION s¢e oF�oz now or�ior S /e � �hereby offirm fhat I om licensed under provisions of Chopter ) � 9(mmmencing with Section 7000}of Div�sion 3 af the Busi- euiio�s �E8• CHARGES � . nass and Professions Code,and my license is in ful!force ond ,� r - effet}. �y Q^ . CONTRACTOR � CONNECTION CHARGE fEE � ��� � licansaNumbar 3768�4 [iC.[�095 u 'TC AODRE55 1 Hamner Ave� A. REIMBUkSEMENTFEE O � '� Van Diest �O1Q 9/1,87 _ DISTRI�f NO. GROUP MAP WiOCE55ED BV � Contractor air TO O TEi.No V BN FG . I;�1 am exempt under Sec. of ihe t.A.Co. �,�ir�� 37�8�Q. aAss �i 2 �`�'��� r7 � O � �. DESCRIVTtONOF WORK iEE l�— f � Plumbing Code ond/or Sec. of�he ���WER mNr�cr��ro F�NA� U I B.&P.Code for ihe foliowing reason PUBIIC SEWER � OQ °"rF/ r�t VALIDATION a � � 'I SEPt�C TANK.SEEPAGE PIT OR Z � FITS AN6%OR DRAINfIEip FINAL i DOf¢ Iq�S(5(WER CANNFCIIhIG Tp BY { FRIVAiE GiSi'vSFi 5'i5T' a Signoture CDNNECT AODITIONAL 9LOG,OR � � �WNER-9UILDER DECLARAT�ON WORK70YIOUSE$fWER OVERFLOW SEEPAGE%T,DRAINFlELO . I here6y affirm thm I am ezempt from ihe Conhoctor's License exrN.,cEsswcx,oavweu.euuµaoie law far ihe following reason(Secton 70.31.5�BUi5nes5 pnJ Pf0- AIiEP,REPAIR OR ABANtXMV FKK/5E t f855i0fI5COCJBJ: � �� � SFWERORDISGOSALSYSSEM $ ❑l,as owner of the property,or my emp(oyees with woges os ��� r'`N� E rheir sole compenwuon,wlll do the work and the s�ructure �� � � � � C t is not inicnded or offered#or sale(Sectiort 7044,Buainess � and Professions Code). OWNER'S Petmit E 1� � 1 • •[7�(i � ❑I,as owner of ihe property,am exclusive(y cortfrading wirh AUTHORIZATION TOTAL FEE � Q Q � IICBfISCd COfItIOClOf4 f0 COItS�tlltl IFl@�JIO�fCt(SGdiOQ�OM, ., �}�pyE pi THLI pAiE A.WMPALT..WISH SHE MEREW NAMED GOMGKTOR TO e e •� i,�C�, BVSiI1855 OIIfI Pf0{BSSIOfi9 COdB�.' � - � CONNECT THE ABDYEOESCRIBEb E%ISTING DWELLING f0 THE PUBtiC SEWEk.� � �-�- �- � � -���- -� CONSTRUCTION LENDING AGENCY � �(A C�—�i'] � . hereby affirm thot there is a constructian tending agency S�GNEDTHIS DAVOF .. . 1q_ ... . ... . .. .. or the performante of the work for which this permit is �`h'NER OR OWIJERS AGENT � SSUBt��.�BC.�1.�IV.G.�.� A��RE55 � ender's Name eeder's Address � certify thot I have read this application ond state that the bove information is correct.F agree to comply with alf Co�nty � rdinances and Stoie lows regulating�lumbing ond Sewers, . nd hereby uuthorize representativea of ihis County to eNer pon the a6ove- ntioned property for inspecti n pur ses. € Signoturao ermiffee Dat �� � SEEREVERSEFOREICPLANATORYLANGUAGE � � r�.� . . ..� .-+r s �t�•� �i�r�,�� � • 'sq."�w°' °' d-mi��Y Q.X� a c K o oh, �',c o��,i�+ . 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