HomeMy WebLinkAboutNo Permit Number — — — — , _ ____ _ _ , �
WORKERS'COMPENSATION DECLARATION �
1 hereby,offirm that I have o certificate of consem to self i � . }1
in;ure,or a certificme of Workari Compensation Insurance,or �6A661D ��f` r U
c ceYfied co���g5�f 5���,�ab��remont Indemnity0e'RE�.,,e'� APPLICATION FQR PERMIT
Polic No. e
❑Cerri4ied copy�s hcraby furnished. SFWER • SEWAGE DISPOSAL
❑c���fied coPy�s flied wi�h rhe county building��sPecroo COUNTY OF lOS ANGE4E5 BUILDING AND SAFETY
deparlmenL �
Date��1F���ant�.�.rg b+ . FOR APPLICANT TO FILL IN CONNECTION DATA
GERTIFICATE OF EXEMPTION PROM WORKERS' euimiNc
COMPENSATION WSURANCE A�DRE55 349�. Arneitos Plac sT°'Ti°r�' cevrN
�7his section nead nm be complefed if the work involved by the �p�AUTY Diamond. Bar ^n.4NHa¢rsereaeNc[ urrtR
permit is for one hundrad dollors(E10p)or less.) . , ��R
I Cer1i{ thtll in ih¢ r�EnR[S* TYPe OF COniNECTION tENGTH FROM
y performonce of rhe work for which this ceoss sr. v. cuae P.L M.L.TO P.l.
permit is issued,I sholl not employ any person in any manner
PCNO.
so as fo become subjact to ihe Workers'Compensation Laws. owrvea CO,IMP.NO. JOB NO.
Date Applimnt
�RE55 .P..O. BOX 33 TRUNKPERMITNO. ROADPERMITNO,
NOTICE TO APPLICANT: I4, oftar making this Cenificate Of ��T� Covins - TE�.,.,o, 967-9541 AFFIDAVIT WAIVER EASEMENT RECOR�.INSTR.NO. DA1E
�emption, you should 6ewme.subjec� �o the Wo�Aers' LEGAL
�pensalion provisions of the lobor code.you must forthwith oescRivriori �orr+o. nwr.oa sr.wioENin�
�..mply with soch provisions or this permit shoil 6a deemed .
revoked. � etocK iRACT STATE ENCROA�HMENT
LICENSED CONTRACTORS DECLARATION . . e PERMIT NO.
512E DF LOT -NOW ON LOi
I hereby offirm thot I om licensed�nder provisions of Chapler �E oF
9(commencing with SeUion 7000)of Division 3 of�he BUSi- BULLDINGS Resid I].tl$�. cNarscEs
ness and Profess�ons Code,and my license is in f�ll force and (' p T
Bf{E��. �pNTpACiOR � •`�•'�• i umb ing� ln.�.'. 40NNECTION CHARGE FEE
License Number�,e�,Y4'ttC'�p55��_ ADDRESS � REIMBURSEMENi fEE � �
L-O"
S�� OISTNIC7 NO. GFOUP N.4i YROCESSED BY n'
COMld[IOI��� CITV TEL.NO. • � eK � Q
❑I om exampt under Sec. of�he L.A.Co. iiCCNse rro. • � anss � � �
_ aC
Plumbing Code a�d/or Sec. af�he NO. DESCRIP710N OF�WORK rte FiNA� p
FqUSE SEVJER CONNECIING TO � �.- DATE f7�/Q„G� VALIDA ION �
PUBIK SEVOER
8.B P.Code for the followinq rcaaon $[oTIC TANN,SEEPAGE Pli OR F�N� � p�,,,
PITS ANDiOR ORAINFIELD _ J� N
Date hpUSE SEWFP ODNNECfING Tq BY � �
' RtIVAT I3POSRL Sr57E
$ignplUfB �pNNECT AO�ITIpNAI BIDG.OR � �
OWNER-BUILDER�ECLARATION M'O�TO NOUSE SFWER
I hereby offirm ihot I om exempt from the Controclor's License E%TN���C SS FPOOL DRVN'EILAMANHoie
law for�the following reason(SEC10I1 7O3�.S,BUi5t1955 OI1fI Pf0- AL7ER,REGAIR Oq ABANDON NOUSE
("`"`4iOn4 COCIe�: SEWER OR DISPOSAL SYSTEM .
�1,os owner of the property,or my empiayees with woges as c�� 2']•2 A
iheir sole mmpensation,will do the work and the sfructure �
is noi intended or offered for sale(Section 7044,Business #• • • •� �
ond irofessions Code). OWNER'S Permit s ,S`(f
❑I,as owner of the property,am axclusively contracting wirh AUTHORIZATION TOTAL FEE I • '2�.5 Q
licensed tonlratlors-ta construct the(1lO�eCt($eC�iOn�O4I, I HAYE Nl TMIS 0.4TE A C�NiRA�T WITH THE HEREIN NAMEO NTRACfOR i •��/5 O
BU91f19S3 O�d P�OIC4510�5 COdC�. CONNECT THE ABOVE DESCRIBEO EXISiING DWELLING TO THfi PUBLiC SEnER. � � � i c�
CON5TRUCiION 1EN01NG AGENCY � D 7,1 1.-8 5
I hereby affirm fha� there is a consir�ction lending agency SIGNEDTHIS DAYOF 19_
for ihe performonce of the work for which Ihis permit is ��RO°
OWNERS AGENi
issued(Sac.3097,Civ.C.�.
PDDRE55
Lender's Name
Londer's Address �
I cerfify that I have read this application ond sfata ihot the
above informdtion is correct.I agrae to comply with oll County
ordinances and State laws regulating Plumbing and Sawars,
and hereby aothorize roprasantotivez of this County lo entar .
upo�.ihe,pbq+�e-m�qfy n properry f �inspectiop purpqsr�,r
1C l. LC 13 a/c i
Signature of Permiltee Date . SEE�lVERS!FORlX�LANATORY LANCUA6E �
R.C.R. PLLrtw�TNr
. _
_ ��� �_,��. IP:SP�CTOR's tiaTES OWNER-BCIILD�R llE�LHic.QTYO'v
��
__�..,.. _��•.+,...__
� A.°''$i i�C�:,L$ � �"r'� ' �c'}OL�"'� ' __ _,_ � _� I hercAy affirm that 1 aiti exenipt frum fhe Contr:�ciur's �
as,
�. '
� ��w u s . � � � � � � � L�cense Law for lhe fnlloN4nq reasoa (Sactkxe 7931.5,
Y, _ .__, ___ _ . .�__' Busu�es.r aml YroJessians Codrl:Any citp ar caurtt��shech
`� C'A � .°, �'I� � - , � � reqmrra n permit fo cnres[n�ct,alfer,unpruve,dener,Qi.ck,nr
���.r w ow�n��.�. �_T__, � _ ' repa�r any siructwe,prinr!o its iasumue alxo reqr�ires the
----
� �— —'-- -��.-- �-�--- -._.—..- --
r,+ae��o oans �,:.o�... �� � . . , � .. . � . . . a�pleCarH for tueA p.•rmif ta file a s�igrt�d slufrfnrn(thnt he is . .
c a_or � e�.s;e.i❑ -�-- . - � � . . .. . . -- -- licenaeG pursua+ei [r� thc provisiorrx �ehe Cantracter's
_ License Law(Ckayler 9(eomixenciny w�ith Section 71H19)oj
�_re,. �' n -rv� �p,. .���, � . . .� . .�. .. . � UiVisio��3 of fhe Bu.sieess artd P7v3feasEons Cate)nr[kat!ce is .
___....___.____ ___...__ .._- _.___'_._�-
Y
�rv, c n �. . ____.___'_ _ - . exerHpt thrrefrorrt axd tke 7�osi�jw the altr,yed exemytiAn.
C._.r(' I F 1�:A 1: __ .- . . . . .
nNnn���.N�u e s w.k� � - ' Anj�aafatini�of Serliar�7�3l.5 hy an��ap}+lirant fvr a psrmi£
=.a s.nc rqn s[7 ' ' �' .'� . � subjrcts th.e applic¢nt to a civif penalry of nnf ri�ore lhart ftve
ser �.❑ cE�.:.ois n . -_-- . ---------- hursdred doller.r($5(XI).: �
..._.�,_e__...._�.._____@.-:�.-_..a. -..s..e_.__�_,�..� ....:....,��.....�. ---�� --�-- .:__-- -
.. � , , ❑I,as lhc owner at'the property will do the e�urk,aad '
� . � � - ' - �� � � � � " the structure is�t intendtrl nr uP��cd ftv sak.
. _._�___.-=------ ---..
� _ .. . � �. � (Sr(�.7f1i4,Busixess and Prr�fc�asienc Codr:Yine Coxlraw'eer's
� . .. . � . , . . - . .-,---_-----. - -- Ltcense Lnw�dnes rmt oppfy ta an ownrr of Prr�/rertf•x'- .
. . . � . -- -- -�— . bui(ds or i�A�rave.a[hereox,and x�hn dnes such M'O/A{lUft.\
� � - � � . _� _._ procidert lhat such irnrrrnvemerttr are not intenda•d or qtfered �
� � , � . � � -� � for sale. !f,Itowever,t4c LrtiWixy nr iwprncewent is snld .
• � , ___.__ �_,..,.__ ._--_.---_-,----_ . . wifhiironeyearofconeple[ion.thenwnertiurlrlerwilflin��ethe .
. . . . . . . . . hurden of luavin{p that!w ded nrN bri/d or iix�'or��,pnr tAe
. , .. ' —.__� -_..--._____—,._-- PMrpese of sale.) .
----.-,_.------- —_ . I am exempt uade�Srtc.._
—.------------- ii.Yt P.C.'tbr thik re+�c»�. .--
,
< < Flafe
_ ------ . O�nee
' IMStECTCR'S�HC1Tf5 � ' � . � �-
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