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 �
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