HomeMy WebLinkAboutNo Permit Number WORKERS'COMPENSATION�ECLARATION q
'�� I hereby affirm thoi 1 hdve a certificate of consent to self 99-OWY DWJ 3:8] ,
]bA6�]D 1S
• insure,or a certificote of Wwkms'Compensation insurance,ar ce eae
- a certified copy thereof(Sec 3800,.La6 C) APPLiCAT10N FOR PERMIT
� Policy No. Company �'-- SEWER - SEWAGE DISPOSAL
� ❑Certified mpy is here6y furnished... -� . . . � � �- - �- � � � � � - � �
�� �Cer�ified copy�is filed with+he county buHding inspecrion �� CDUNTY OF LOS ANGELES BUILDING AND SAFETY
department ... - � . . ...
� oa�e 9I1/87 Applicant Van D�est & Son. Ine. FOR APPUCANT TO Fill IN /f— . CbNNHfT10M DATA
� CERTIPICATE Of EXEMPTIpN FROM WORKERS' � eui��r+c � � sinnoN �.� . � o�v�H � � � - �
. � CAMPENSALION INSURANCE. � � �. . �ooa[:s �799 1'43.Bt �ID�ISl• �� �
-� �Thie aection need not be completed if the work involred by the �12NDjlf� �T .. � - t+w�+Ot�REFEVEt+CE �� �' " ' uaa�R . ,:
� �ocntrtv 1 � �� . . w a
permir is for one hundred dolbn(51001 or less.) � � � � , � .. . .TyaecyFcorx�eC*ron�
NFAREST < IENGTH ffNM y.C)'.
1 certiiy that in�the perfo�monte of Ihe work for whicR ihis �� Ca�551i. v.... �cwB vt� re.i.Tov� _ _
�� permit is issued,�shol�no�employ ony person in any manner � r c rap . �
. so as io 6ecome subject to the Workers`Compensotion Lows. � owraa . .. .. . . . m.1�+�r-c+�. ...-----_ ---..--.�os-N°lG �. ..-. . .� --. .
. -.. . . .. .- _. ._.. . � .- . MAtI TRUNK GERMIT NU RO��PERMkT NQ.
oa�a AVPi«�r _ _ ��
NFIDAYIi WAIHER EFSEMEM RECOWD.INSTR_NO. DAIE
� NpTICE T0.APPlfCAMT: 1£,.affec.moking�this Certifi�pte of �iTy ret.t�o.
Exemption, you should-.6ecome subject .tu the Workers' �� �
Compensotion pravisions of the labor code,you mu:t forshwiih p[5�qip{�pry� t0T NO. 1 wwr pa sr.wioebrnc
' comply witfi such provia�ans or tbis pefmit shal4�be deemed �� ��(� A �I
� revoked. aicicK TRACS `}'t��Y y r STAIE ENCQOMCHMEt:T
......- NO.OF BlOGS PERMIT NO.
LICENSEDCONTRACTORSDECIARATION sizeoF�or doworrwr ,�/� �/ �L
�I hereby offirm Ihat I om.licensed undC�.pro.visiuns.of�hopter �� /� ��'K'
, 4(t�mmencing with Seolion 7000)of�Division 3 of fhe Busi- � aurto!n��s Res: CHnkC�S
• neu and Professiom Code,pnd my license is in full farce.and
;1 lffeC}. ��,^��. . .. . . . ^.�n... . CONiRPROR • CONNECiION CHARGE FEE
00 {! L }
Licenie€`lumber L;c Clau _� -� �oorsess � 1 �H3IDIl0r AV@. � ��MBUHSEMENT FEE �'
9/ / 7 �
�� Comrac�o�V�'+ Diest Dare 1 8 �OTCO 'i'34�'j�,2 DISTRICT fJ�. GROU� rn,aP PROCFSSED 6V �t
atr � iei.No. /�7 ez Z
❑t om exem t under Sec. of the lA.Co. �q� p ��� � K J �. � O
{I U�NY NO. p CLASS F
- Plumbing Code and/o�Sec of the NQ- DESCRIPTION�F WORK vee F�NAi U
� Hous�sEvha coNNecnr+c*o �7 QQ oare �,/ �. VAUDATION a
B.8 P.Code for the following reoson Pueuc scvrcR Zj?�' rn
SEP11C�ANK.$EEFA[iE Pli OR FINAL ?
� DO�@ P�rS AND'CR OkAINFIEID
. HOUSE SEWER CONNECTING 70 a}
VRIVAIE DI l SYSi M
, Signature �NNEC�AD�ITIONAL Bl�OR �
OWNER-BUI�DER DECIARAT�ON woaK ro Mous��wta
� OVERFLOW SEEPAGE PI7,�RAINFIEi�
I hercby afflrm�hat I am exempt hom the Con+mctor's License [xrN.,cessvooi,owvvreu.n+aNuote
- low for 7he following reason�Secton 7031.5,Buisness ond Gro- /.t7Ek,Revala Oc nerwoO�+HWSe
f@Ssions CAde�: SEWER OR�ISP0.5Al5Y5TEM .
❑1,as owner of the property,or my employees witb woge:os �r'� ���� i
their sole campensation,wili do�he work and the strudure {�• •�•'� V �,,
is not intended or offered for sole�SeUion 7044,9usiness permit ; �Q 5� �
orrcF Professions Code). OWNER'S ( • �G���Jr� +
❑�,os owner of the property,am exclusively controcteng with AUTHORIZATION TOTAL FEE '
��r..
�ICBfISCd conlrac�ars to constr�tt fhe projec�(Settion 7�44, I HAVE AT THiS DATE A CONTRI.Ct WITH THF HEREIN NP.MEO COMRACfOR iD • • •7�,J(�= �
BUEInBss and PfOfC35i0�5 COdB�. CUNNEG7 lilE A80YE Cf$COIB�'D E%ISIING DWEl11NG TO�ME PV&1C SEWER. �
CONSTRUCTION LEN�ING AGENCY � �Q O�—�7
I hereby offirm thal �here is o construction lending agency 51GNEDTH15 oarOF 19_
for Ihe perfwmance of �ha work for which this permit is owr�iEtrs�[r+t
issued(Sec.3�97,Civ.C.), (
AOORESS
Lender's Nome
Lender's Address .
- I certify thoi f hove reod this applimtion and state thal the
obove informat�on is wrrect.I ogree ro comply wi�h all County � . .
ordinances and Stafe�laws regulati�g 91umb�ng and Sewers,
ond hereby authorize represen�atives of this County�o enter �
�po e above-me tioned property for inspecfion purposes.
$i nal�re o rmitlee Dol ��� SEE REYERSE FOR EE►UNATOXY LANGUAGE
� n oti m �,. t � `�y m`ti e m
ov�� mei �,� � c.�"'' n a o ° ot3 .�. ° 01«
^� � o �.. �i �� �°w °C U .'ti � �'�
-�. m O � '�0.��.��. a.o� q � .!G � G c � �m� �' . . . ,
0 ���.2 w -G:.M � ef O �i �� P a �� "ti
r.i o � p'` M �V' .� �, � y� ai[. n S Q � G v m . . -
E'� U..n. �:�.w...w. ��'O m C"�.v CJ q R'b }^.O b "' p '
C. Y °iC� � � an��� kn � pp�oa �k.a � � �
� �`� e iY�Y u n `;4 0 '�o V " �'v`�'°�;,: ��
q R �'�.Q'Lf y q w d C.�,�, � N ae,?�o „`'
U � a� � x � o�i a� a a`� B d o ry,� �'� '�'^°�� �
•' � M N � w�Dy 7: `�'�M tl ti�•�.�
W aFw m a � �.;;►7o w � x cm„ �w m v a�i '` �
A �i �o � ��:,�'_h o't�a� ":r p.c c�°. '' `ti" �'� � 6�i y � ..
� �•av ° � x•� o`�v ,,'°�'�=i�'E0. y�,d a:=-:o cn �
A �w o•sr��;�� s��-� 0�m w�,� d a'p'���� �,� .d �n .
� s � ti 6 n y a o t% vh, ��++�.w � N �tp � *L y w �b C'' y�
►"') ^4?`ti'°�� cs "'V.Q`ti y � � � w a � �� o o.p F+ �.
-4 O' ►7 b�O o� �
�i B w � '�4,�e, ~ "� 4 ,"Q.«'�� G C � x �m 0.m «� �A' O
a mB�� � �`,,��bda;'�+ o'"'� � o�s"����� _� �
� ,� ,� �o � :: y�ano� �� ��;.��1�•a: xoKe.�'ti _� ?.i �'
�'„d � p,.Q O '�' p m h � o �� w p O.y w p " �Y'�, y �" � � �
�
O y ��-�a �'m�� �''�� d-��°°,'y^ o m � t�"'rm,,.� � °° �q A
.. � �„� ° a, O� � °�'o"s$❑ " d� $.n :� �a,�. ..,
a¢S 3b�V�Si `.��w�A rxi� �`w �h tl� l�O<L
F . . �i
o �..� � .... � I, �
� '.. � i ' ��� - � j I . i
G � � l � ; ; ; � , .
� f ' �. i � � � � , i 1
_ � j j I �� � ' � i I I y ! i i
' I ' ( � I i � ° ',
� ` t � ; _ � � � ' � � �
, 1 ; �
I 3 1 ; I
I � � i : ; �
. � 1 � � - '- :. i � ; i.
� . . ; ; �
11 I � � � , i
�
�
�
Si
N
�
G
�
z
_ �
� O
� Z
o �
�
O
_ �
6
❑ ❑ '�
� � N �
�` � � g� ����
/ Q N
Zs: a� O °�'�'N 4h Z✓`3
� � O O w'-" �� j'�"i ��"J
a� �� �� �
Q � Q� Qo p 6Q Z� �❑
� �z vQ X �i� z s
Z� 5� �J, �w �< �d
, z �m �!a C'i ��, aa �yS