HomeMy WebLinkAboutNo Permit Number _ _ _ __ . _ .
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WORKERS'COMVENSATION DECLARATtON: � � . ��� �/r
I hereby {cffirm that I have a cartificote of�consmt to aelf � r� q"�
in;ure,or a Certifiwte of Workeri Compensation Insurance,or �6A61�� U
p Ct�HIIEd CO�JY iF19�00f(SlC.38DO,LOb C.} - CE8081REV.1;83� APPLICATION FOR PERMIT
voi��rN�. �$5r�3n1�382—Fremont Indemnity
❑Certified copy is hereby furnished. . " � � SEWER - 5EWAGE DISPOSAL �
�CertifiaYl copy�s f�led with the couroy buildinq�ns tion COUNTY Of LOS ANGELES BUILDING AND SAfEfY C�'38`
deparlmenl.
oare p/��cI,�� FOR APPLICANT TO FILL IN CONNECTION DATA
� CER7IFICA�TE OF EXEMPTION FROM WORKERS' �� �iioi�
COMPENSATION INSURANCE nooa[ss 34.3�. Armitos Pla � ST""°" o�°�H
(This section naed not be complered if the work involved 6y ihe ��p�ITY DZSSTLORd. B$r /MNHCLE REFERENCE . ��p
permit is for one h�ndred dollars(5700)or less.j � R
I certify that in the performance of the work for which this �pp�sT . TYPEOFCONNFCTION IENGTHF(tOM
� � Y. CUPB P.l. M.L.TOP.L.
permi�is issued,I shall not employ ony person in any manner South Couri.tr CiOr v.0 No.
so as to become subject�o the Workers'Compensarion taws. owNEa � Y . P' � CO.IMP,NO. J08 NO.
��� TRVNN GERMIT NO. ROAO iERMIT NO.
Dare qpplieant nooaess
NOTICE TO APP�ICANT: If, ofter makin �his Certificate Of AFFID0.VIT WAIVER EASEMENT RECORO.INSTIi.NO. OATE
9 4TY TEL.NO.
Er��mp�ion, you should become subjec� to the Workers' iE�at. �
� �ensolion provisions of Ihe Labor code,yo�must forthwith oesceivnora l0T NO. 1 Z � HWV.OR 5T.WIDENING
te..,ply wilh suth provisions or Ihis permil shall be deemed /. r�
IBVOkOd. BIOCK TRACT`� � L5 . 57/.iFENCROACHMENT �
LICENSED CONTRACTORS DECLARATION � � r+o.ov eiocs. v�amrt No.
size or ioT NOW ON lOi
I hare6y affirm ihal I am litensed onder provisions of Chapler use w
9(commencing with Section 7000j of Divisian 3 of the Busi• ewioiNes d1ARGE5
ness and Profassions Code,and my license is in full force and
9f{BCi. CONTPACTOR CONNECTION CHARGE FEE
LicenseNumber i . noou[ss 1278 ��Ma TSO1�.`[t ' �REIMBURSMENTfEE }
—��a�+l�—C=36 DiSTRICTNO. GROUP MAV >Rp�E55ED�8Y 0'
co�o-a«o. ��_op��_,���85 �„Y Riversi��,,,o_ 371-5000 BK � o
/;, "
❑I om exemp�under Sec. � of the LA.Co. iicerEis�wo. anss � �
�� DESCRIPTIOry OF WORK FEE
Plumbing Code and/or Sec. of}he FiNqi 0
VIOUSE Sf WER CONNECIING 70 DATE VALID TION
B.8 P.Code for the following reason NBUCSEWEa 1 7—/�^�S �
I TANK,SEEPAGE Pli OP FINAL 0'
PITS AND/OR ORAMFlELD /� y�
Date 110USE SE WER CONry[CiING TO BY �
ORIVAT I SY T U O
'J19natU�e WmpRK ip HOUISSEWER�OG.OR ► �� 2 7 3 A
OWNER-BUILDER DECLARATION OVERFLOW SEEPAGF Pii,DRAINfIE�D �
I hereby affirm ihat I am ezempt from the Contmcror's License e�nN.,cessvoo�,oavweu,rnaNNae #• • • • � Q
law for the following reason(SBCtOn JO31.S,BUi5f1B55 OIIE PIO- AIiER,REPAIR OR ABANDON HOUSE . �
,f'""bns CotJe): SEWER OR�ISPOSAL SYSTEM
I • �27.50
�.I,as owner of ihe property,or my empioyees wiih woqes os
fheir sole compensalion,will do the work ond fhe atructure • • e`Z Z S O�
is not intendad or offered for sale(Section 7044,Business Pe�mif s
a�d Professions Code). OWNER'S 0'],� � —8$
❑I,as owner of the property,am exclusivaly contracting wirh AUTMORIZATION TOTAL FEE
Ii[Cn58d COIIfIOtlOf3 ip Conit�uC}iF12 PfO�¢d(SCC�iO�7O4d, I HAVE AT THIS DAiE A CONTRACT WITH THE HEREIN NAMED ON ACTOR TO
BUSInE35 Onf�Pro{eS510�5 Code�. �ONNECi THE nBOVE DESCRIBEO E%ISTiNG DWELL�NG TO THE PUBLIC SEWER. �
CONSTRUCiION LENDING AGENCY � �
I here6y offirm fhot fhere is a constr�cfion lending ogency SIGNEDTHIS DAYOF i9_ �
for ihe perfoimance of fhe work for which �his permit is O`ANEROR
OWNEF$0.GENT
issued(5ec.309�,Civ.C.).
ADDRESS
Lender's Name
lender'a Address �
I cartify�hat I have reod this applicotion ond state that the �
above informalion is mrrett.I og�ee ro comply with all Counly �
ordinances and State lows reguldling P�umbing and Sewers,
and haroby authoriza representativea of fhis Counry ro emar �
upon the,qbayp�tp ntio�ey p- erty for ins ion purpo�aLsl/$5
1C.l�.LC. ti b
- �
Signatu�e of PermiRee Date 3!E REVERSE FW 6X►IANATORY LANGUAGE
--- ir�m�cros:'S HOTes UR'NER-B�JILDTiiE UF.CY.AFtATtON '
� ,..� _ _-- -.....�.,..�.�,.,.,_...�-�•-,
-�-���-�.
d �,��c, n e in cao s s�ri �� 1 Aereby atWrm thet[am exempt frnm the Co'Hractor's
"_.._� __.'_..--.__+.�_ ._ _.__._.-_ _
H
v�;�c� .� -- - - -- � . License Law fa�Nsr Poif�vin�.rsaaio/Swrtion �I.S. ,
- - - _____.___ � � Business aaf Rafersiens Cade):Arw cin•or nratrrn�x•hiek
o::'� r a,..r�i��_ ��^ . . . � � re uires a crrxit en construct,alrrr,im rove.dcm�fia rx �
wn�,ora,c„wiu, - - 9 Y P 6, .
.-:rc ir,Ne ;[r�,c.u<.�---- �— .-`�- --� ---------�'------ — reprtir any struefure,prior!o its issuroce.also requirrs!ht �
aniu. .� �'.Fi.� . � .,. . . .. . . ... . . a�eh'erzn7 fw-such perrni!to febe q se�ee�l staMnrere�that�hr is
- . .____ _O__ __-.�__—_-_-_-__— . . . . . . _
�°��oi �7 e� n-u � ... I . . . .. . . �— .. . " . . ;..�... lirensed pursuar�r fo !hc provisiona nf thc Lbnlractnr.s �
� .-.. — ' Litensc Lan•(C r 9(c�wenerlErn;q wilk Sertinx 7(I(X))of .
rae u� -- : . I I � . � ' �: . . � Uivisimt 3 of[he B�fness and Frnf'rzs'rrme Codt)m-thaf he is
. ��. r s .., ,,., ___.__ ... ...._._ _._ _____—_. —
- . exem�t Iherefrorn and flFe lusr�for 1ke o[h•qeA exem�tinn.
a2.i�ti�rir�H�i� �v.�. � - � ��. Arey�mlebinR of SecFi�sa 7b3L 5 bp wrv appficant fzx a pe�rxit
.-e r 1�N. C - —--� � .. , -.. . .. ' . � . .� � � � sxbjeCts.tftc n�+ficaal tn u civi7 perwlty nf rrnf�purc lha�fve
,;, r f�� c . ._� i 7 � ! . " �. _._.._.. ...:_.. _.___._ __`_____.___ hxreAred dollan'($SOd).:
.»_....-..._ .�,. - �..._.._._....._._._..��..�....,....�. __ ❑I,ns tkc aK�mr d"[he property x�if!�X�the work,and
. . . . _. . _ .. . _;.. . .,.. . . . . . tkc structure is nM inEended or oPPrneft ftrr sak.
. . � .. - . -. � , .... . . � (9rc'.7U6f�Hasirtess a�Arn(esse.rn.r Cnda:The CnpEraeMr�t
� . . . ---- - � Licensc Law does m�[a�rp(y en nx a�,rer q(}nn�rrly .-.
- . - . . � . . � brcJds w iluuproves lkrrenx,and wbo docs sruk x�or8 hia.
� -__.,__- ._,__-_.. __-_.__..:__.___--_�_ proviA:d thu!sudo i�nprovements are nnt inlrnded or offrred
� . . . ' . � . . . .. . � - .(ur sale.7f, lwwss�er,t1W hui4fin�or iuyyrorex+cx(i.e sold .
. . . .__-_.._...___-_____-___________._.____ wiFkin one year of cnu:pletinrt,the ox�ner-hnllrler w•ill h�re[h:
. � - � . . , . . �btEnd�.�n nJ'proviirq t{te!Jre.r7hd not bxi(rf or im��ove for tRe
. � . . . . . __ . � . Pu7rsr q?'suie.j . ' � � ,
_ . � —_ I am exempt u�ader Sec.
, - ----_-- - . ki cYc F:C.hsr Cltim reaspe
. ----- , Dste
_ Owner �
��—�ltiSiE�TOR'S NE3Fi: - � � � . � -. .
� �-�—_-- , . � ... . . . —_- . , � ..