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HomeMy WebLinkAbout01_31_1983 - 1817 PEACEFUL HILLS RD WORKERS'COMPENSATION DECLARATION ' � � � _y� I hareby affirm that I have a certificme oi consent lo self . . . .. � � Zy � .insuro,or a ce�tificate of Workers'Compenwtion Insuronce,or : �^"0°�0 ' � � � � � a certified copy thereof(Sec.3800,Lob C.) - t�eoe(R�v.eiei� qppLICATION.FOR PERMIT - � � � Policy No. � Company ' ., �i � . �c fied copy is he�eby furnished. SEWER - SEWAGE DISPOSAL Certit�ed copy is filed wirh the counry building inspe tion COUNTY OF LOS ANGELES BUILDING AND SAFETY ' � deparimenL � � - ��e �-��� Apvi��a�� FOR APPLICANT TO FILL IN � ./.� CONNECTION DATA �- CERTIfICATE Of EXEMPTION FROM WORKERS' euudrw /� ',�� � . COMPENSATION INSURANCE . �oo�Eu� TJ Peaceful STATIOH 1-a otvtH . , 7 (This section need not be completed if ihe work Involved by the - i��iTy Walnut . ' r�w+��cFfa�r�cE �'�� R � � permit is for one hundred dollors(t100)or less.) . ' I certify thm in the performa�ce of the work for which�his C�sST, n'c�Oc[aarrKiaw ��TM� �� � Y. NR9 ►.l.' MLTOP.L } . permil is issued,I shall nol amploy a�y person in any manncr� p_�_�, v O ao as to become subject 10 the Workers'Compenwfion Lowa. p,�q M. J..BL'OC�C & SOIIS� II1C. Cp,�Mn.Np. pe r�o. V -_ ��� - . . TRUNK VfRMIT NO. ROAO PERMR NO. � Oote � �Applicont � � � AOD�� ' . AFFIDAV�T WANER EASf/AENT REfORD.INSTR.NO. D/+TE Q NOTICE TO APPIICANT: If, aftar maki�g ihis Certifitola of arr . Brea �� re�.r+o. 714/529=8170 � � u Exemplio�,�you should become subject to the Workeri� i� � � W Compensolion p/ovisiona of the Labor code,you must fwthwi�h pEURunqN 'wTn�o.� - -- Hwy,pt st.w�oewru� � � �' comply with wch provisions or ihis permit aholl be deemed /� '� � ' fBVOklA. � . .. lLOCK 7RAR ✓ S ' . . . STATE ENCRO�CHMENT - � LICENSED<ONiRACTORS DECLARATION . � ra,a&°cs. . r�R�T�a. _ �zeor.iot 7200 sf niow«+wT 1 � � I hereby affirm thot I am litensad vnder provisions of Chapter � 9(commencing wi�h Section 7000)of Division 3 of the Buai- g�ii�liD�r�s Residential au.Rt�s ' . neu and Professioos Code,ond my litense is in full force ond . . . � effect. � �''��'' v�����,���'''^ /� � � [OUTRnctoa y].d111�T Construction� CO""��iON�"""�� � License Number�dfk.Clazs �-/ � . � ... . .. . aciMeurtse�Nr r�e � � e �@� �u 1849 W. Re atta Road Com�oao.��1��u�JLMiI�!IJ I��I—O+� arr hi.r+o. . asmierr+o. e�ea�r Mnv PROCESSEDBY ❑I am exem 1 undar Sec. of tha L.A.Co. . ��� ' � °C' � � �� /��/�� ' P IICENSE Np. QA55 r . . . rJO. DESCRIPiION OF VJORK rfE � . PlumbingCodeand/o�Sec. ofihe FNA� , VALI ATI�(�, � . . HOUSE Sf WER COIJNECTING TO ' D�TE B.6 P.Code(or 1he foilowing reason � � Puauc sewek� �- -,� � - Q(/ ,� ��� � - SEVTIC TANK.SEEPAGE PIT OR � FINAI - � ' - � VI75 ANO/OR OIUINFIEID � DOte lqli$E 9(WFp CONNECTING TO B� - � PRIYAIE�ISPChFI SYS7EM ' $lellOWt@ � COMrECTADDITICM�Al6lW.OR / _ . � . � OWNER-BUIIDER DECLARATION � �K ro���� - , .. . I hereby offirm Ihat I am exempt fiom tMe Conlroclor's License exnu.�cessvooi oarwe°�RiAmuu`H°q[ ' �� Law fw the following reason(Secton 7031.5�BUiSf1855 00(I RO- TER,REPMR OR A6ANpON MOUSE � ' � � � - � . fGSSiOf15 COdB�: � ' SEV+ER OR DI$q7$ql SYS7EM � . ❑I,as owner of tF�e property,or my employees with wagas as . � �heir sole compenwlion,will do tha work and fhe slrodum � � ?(�(�$,5 A . is not intended or oHered for sole(Secfion 7tlM,Business , and Professions Code). OWNER'S Permit f /J Jf �. . • • � Q ❑I,os owner of the propeny,am exdusivaly conrracting with AUTHORIZATION TOTAL FEE � Iicensed coNractors ro conslruct the project(Sectb�JOI4, I HAVE AT TNIS DATE A CONTRACT WIiH THf F1ERfIN NAME�CON r.aat to � • '2 7.5 0 �� Busineu and Wofesslonz Code). ca+w�crTHe neoVEJ'�ESCW�BEp EXISTIf�0 T G TO THE PUBLK SEWF4. - -' - ' �� "-� " �� ..-- - �' ' "' - - � �CONSiRUCTION IENDING AGENCY � b S� ' � . � • • •2 7,5 0� I Mereby aRirm tlwt there is a Conafruction IBnding agency SIGNEDTH � DAYOF - � , � � - � , fw the performance of fhe work for which th -permit ts ��R�� . � pWNER$AGENT issued(Sec.3097, v.C.). . �E� . _. . . . 0�j,2•� —Pi�J , lendei a Nnme� ' . � � . � Lenderz Address � . � . I certify that.l trove reod this opplicolion ond slole thot tMe " � . .. . .. . . . . . . � -. dbove loformalion is tonett.I agree b tomply with oil County � � � . �� � . ordinances and State lows raguloting Plumbing and Sewers, ' � �� � � � �- - -- - � � � and herl6y aothorFe representa�ives of this Counry to enter � . - n �e abov nlioned property for ins tion p osez: � , . ._ - _ _ . . � vcae.z� � 3� �� Signolure of Permittae te SEE REVERSE FOR EXVIANAfORY IANGUACE � , 4 , � . � � - ; . � ' - I '--' �. ' { ' SG D� �D � Zv 50 7 i . ' � . ' . v� �n Dp {y�n on �Z S O U `0 Zm i ._ , _ �-� ' .,/ . , - ti:.SZ ''n.'� O �y41a � � ' -.-. . . � . � ' '�'.." Ta �D �lZc OD m "0 ,�� - ' ��� .. ._. '. - . { � �(l �C� 8�n O Z� 0� $ 70 . � . . . . coc - O � Dm �u �. - . • L � ' !.. . m D tn� N� 3. py lc2 p O . v ' a , . . ' ' . ' • '� U^N �Z yp A �^ � i f 4 1` _. . � � , �. � � $Q AO �A � N , V� ` � J � I � N . . • � ` . ' - i . ' �/'�S � i �1 r� � ' �, ' '' ' � I . 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