Loading...
HomeMy WebLinkAbout1036 S COGBURN LN (5) � ---- ------ _--___. ,.....__ _ WORKERS'COMPENSATION OECLARATION � � �I hereby ofi�m that I have a cer�ifi�mte af consenf ro salf � � insure,or a cert�ficme af Workers'Compenwtion insurance,.or ��e� . � � � � a«.,,f,ed p there$f�Sec.3 �b�. �����°,B„ APPLICATION fOR PERMIT .Pality No. �.. �Compan�� ���� 0s �. °� SEWER - SEWAGE DISPOSAL .Q Certified mp�i e.eby furnished. � � (�[eiiified copy is filed wnh the tounty 6ui�d�ng inspecrion COUNTY OP 10S ANGELES BUILDING AND SAFETY .. .-dep�arrmenr :oate 31131f3t.�Applico � � ' FOR APPtICAN7 TO f11.L 1N CONNECTION DATA �.��ER7iHCAiE Of EXEMPTION FROM wOR �� � eu,a,,,,� • - � ,. ___,GOM.PENSATIpNINSURANCE_. ».voeess��`I ,�i7 �-��;�- ' i sT�T�.� � � � . ffr�H ' �� �{This section need�not 6e complated i{the work invo ved 6y rhe - t�jn, � -�'� �� � �,yNHaE u�r�rt�r� � . � . . �,,,��� uE , �� pe mlt Is for ane hondred dollard�$100}ar less.} � � � �� ���TM fuoxt . . -.:_ .- ... .. .. . tEAREST . __ r rvPE OF CAHMECrron - 1 cerfify.-�.thot:n tFie perlormanca p�ihe:.w.ork for�,which tfiis - Ca05asT;' :.... : - .�. y - �,.�. oi. nu.ipv.�.:--. �i.... . � permil,is.issued i_shotl not employ ony person m any manner P�N� � _ p p Q . so nsto 6ecnme subject ro the Workers'Compmwtion Lows. .� OWNER �„�Q� � � � � ` ��Mv wo •-�� � �,roe ra �/ / .._� .v nwa _:-�._ . .___ t'y�::... ._.... ..._ _ . _ . - _. _ � OatB Applicani . nonrzEss �'VI1� L .. '.. IA/�NKPERNUtfJO. -....:. . _RpADYERMtFiJ6,..__ . .._ . p� � AFFIDAVIT WANER EASEMENT RECOR�.iN5T1t.ND. DATE � . NOTIGE TO APPLICANT� If, after making lhis Cenificote of Crr rei-rro- -C� - ~ � F-@mption, you should become svbject fa iMe Warkers' �Ai � :ipensotion provisions of ihe labor code,you musf faAhwith p��pivrippr lOTNO. HWY.ORST.WIOiENING .N ..npiy wifh such provisions or ihis permit sholt be deemed � � reroked. � etoac TftACT � ' ST4TE ENCROACNMEM LICENSED CONTRACTORS OECLARATION Iyp,pF&p65. PERMIT NO. � 9ZE Of l0T NOW pN lOT j I hereby offirm rhat I am licensed under provisions of Cfiopter ��� . 1 9(mmmenting with Sedion 7000)of Division 3 of the&1Si- gU�LDING p�nccEs � nns and Profeasions Code,ond my license is in 4uf1 farm and I effed. corrtkAcroa corvrrciioN tnr,t�+ � ! license Num6er ��lia Class ADDRESS � REIMBURSEMENT iEE /� /�t �/r) DISTRKT NO. GROUP MAP vROCE55ED BY � C0�1�OCiOf�� DrLJ Date CIiY TEL.NO. -QO/L+ � � .! � ❑I am exempt under Sec. of Ihe i.A.Co. iiCENSE�o. �7� °C- ��' � {� canss �t7 � x.,•v..��-:� Plum6ing Code and/or Sec. of the �� DESCRIPTIpN OF 1MORK FEE FlNn� HpUSE$EWER[pNNfCTING TO on VALIDA710N � B.8 P.Code for the foilowing reaso� PUBIIC SEWER � QO � . SEPTIC TANK,SEEPAGE 91T OR FINnt %1S ANp/OR DRAINFlELD v �� HOUSF SEWEA C�IJNECiING TO BY iRIVATE DI Al SY51EN� � $19n01u ' ` CpryNFCT ADDITION/LL&DC.OR � - OWNER-BUILDER D AT WORK TO HWSE SEWER OVERFIOW SEEPNGE VIT.DRA�NF�ELD� I hereby affirm ihat I am exempi ro he mmctor's License EXiN.(FSSPOOI,DRVWELL,MANHOLE Law for the fallawing reason(Sec O . ,BU�Sli663 dlll�Pf0- ALiER,REFAIR OR ABANDON MOUSE fP•sions Code): 5e�v4R qt oi5so5at Srsicrn � �,as owner of the property,w my employees with wages ns �Z,2���8 A , their sole wmpensation,will do the work and the siructure � #��• �.� C is not intanded or offered for sale(Section 7D44,Business � and Professions Code). OWIVER�$ Permit f �Q,��'J � � • �,�7 5� ❑I,as owner of the property,am exdusively conrracting with AUTHORIZATION TOTAt FEE d ��- �/ /� licensed coMroClors fo construct the P�O�BC��SECiiOtl�OM, I HAVE A�THIS DA7E A CONTRACf WITM�HE MENEIN NAMED�CANiRAC10R TO � �• �2 !.S�/U BUSilte54 bn(I Ptofe53iOn5 COdE). COIVNECT iHE NBOVE DESCRIBEO EXISTiNG DWFILING TO THE PUBUC SFWER. CONSTRUCTION LENOtNG AGENCY LLL � C�2�I'�S u I hereby affirm that lhere is a conatruction lending ogency SIGNEDTHIS YO C 1SL=j for the performance of the work for which fhis permit is �NER OR issued(Sec.3097,Civ.C.). � owNeesnceN ) � � aooaEss ll�11` tander's Name - Lender's Address � I certify that I have read this applicofion ond srate that the � - a6ove information is corretl.I ogree to comply with all County � . � or4inances and Stote laws regulatinq Plumbing and$ewers, . and hereby authorize represematives of this County ro enter � - upon the above-mentioned properry for inspection purposes. � . C�.1�'�t31 ignatureofPermilee Dafe SEEREVERSEFpREIIP�ANqTORYUNGWGE � �a £ s�� q�. f� � �s Zm r,�o '° $ oy �,� � -�O - � > m .. �`� 8i� � AK A� �' 'Q . " q � y �L� �L � . O���A m� Az p L �4� �� p �� � . �'y y �A „ �, � ���pz m p � � $� ; a . ' � -'i o s �, b � � O � O � p N . �n '�,z O Y � C � m �� { ' Z r b . � 1 . �� � _ ,"' D ' � � ' "` '� . � ' :.. ' �' , . � ; � ' � � � � . . � � + � t „� � o ��.�� � ' ' a'^ �'.D'�Oy O y � ��'J =�.,� � ,�,� � 1 e* i�'' 4 H .R ��''. t� .4 ..: � rn � 1^-"� � 1 1' � .;s Cn Cf Q W��i'� � ' ia'� n�p �n �,,.-': �. ' � e� a'y � � � �'' m r-� ^ .K�,�,,,,, i�N.3 v� �,�- x, a t' Y, � � w.o„c rm ^ •'a •• � � o o .. X �; � ; � � � ��+, , R`_,•� E- � C ,,,�.r p y � :� � �, .n� �i .,�'�. "N' � `c`�..�M�° � L vi�n� 7 a'a'.�^Y �.`'�»� �, � hd� � �` t �� �S �1 � 4'� a �, ...7a M .7y � -^:i n N P+G W A. � ... e. � c: p `p �' '►°� � t�e '� � ^ ,. �, Z's ..n � O 4.'�v' e"+ `�+ • "' � '�i.''p F �; ^ C'� O p' F�� '-S.�G �y � `.'S+.O ��w� O.»�n �^`., h 3"� p � .,•O"-. r.,� r��. `' :�' � � _.. i-- .., MF �•a w ;�' �� ., `�°� ^b `" :N a ,-�� �r�'{ .y� � fD ei s�+�ti+`^. F`.,ic � ^�v ^ G � �' O �'o «.�,'u pt ,",�u � i". /`� ��°�'` ,.�n,�G'� G'="�;; "J r•(kt'i•0 wr„' �i p � h ;s O h^3 � iV , C.'�j K �a . � 't.«r • _ yF, ry ��F, O�, '� O w' � n �Up ., � '� y � " � �r.F"Ky��.a.�,`„��;2,p.4.� �v, C <. `7 .=`, '� �� �^1 r��^ `�k t+.�'. e A.'*"�Y '�^ �q O+G ' «"",,,^F n �i�r A v� � N 'y O O �f'+' µ N� K�. �.S-.p.c H�0 r, ci`z �i-t � � " 3'�;'`-'�{ � � r� . N Cjf ¢'i `,^^..� h o,"a s�:.�� ""c A" -�i'� „ �� f � v, tD.... ,°��, -t o '4 a �b U n� `;''o g,�'C 'C'`�' »«'?'� . � p (�� £ y:� �•'� � �a � , m � w �i`w � o ��.e o Ci � m m a � �' � K a � °y '.w =� .:F � 'z �. -.,a �� �,w r. � �::t C7 .t . �•�S'.�..`+.� � O �^ C.� w� `� `� C p � v� � �� _ �.. ."� C��„ r � � O c' ao �,�', �' � � -°�� � wa � �• ow� • - `�'�' `�` � a a�u.� �r�^. E � �' � K o'er o�� � �.�o .. � v'w �ia�� ��a �' 1°�'° ,�,��y s A c� ��2 - '' . � � �L � 'C'V' �."�,;... � :�� v h} p U^ to ; ' O�� y x � � a a -� �p�,"� r„� r�..,,., � �� `h� � m �, � rr^ . � ✓,,,,..r . � �`..+""'.�'^ J