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. 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