HomeMy WebLinkAboutNo Permit Number (5) 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 �
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