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HomeMy WebLinkAbout1769A � ' 'C�AAPEN&R�"t()fY DEELARATIOIV I heroby off�rm that I have a certificme of consam to self {� insure,or a certificate of Workera'CompensaAon Inwmnce,or 'sAb'�o II Po�����a�t�n��`;�,� C808 R`",,"' APPlICATfON FOR PERMIT ° ❑Cartified copy is hareby furnished. SE�R - SEWAGE DiSP05AL ❑Certified copy is fuad with�he m�ny 6uilding�nspedion COUNTY OF 405 AN6ELES BUIIQING AND SAFETY depo.t mn�.�,"/ �,,�s � Do�e_`�Z� F Applicant_,_/�� � FOR APPLICANT TO fl«IN CONNECTION D/I�TA CERTI ICATE OF EXEMPTION FROM WORKER$' eunoiNc � COMPENSATION INSURANCE ADDRESS � {� � srarioN o[arH (This section nsed not be tompleled if the work involved by ihe �«A��TY ,v�aN�7o�E��Eqf�vcE U°� perm���s for one hundred dollars($100)ar less.) I CM�i( 11101 in ihe �A�S� TYPEOFCONNEC110N IENGTHfIfOM y performance of the work for which this cxossst. co�ee n.i. m.�.rov.t. permil is issued,I shall no�employ any person in any manner Y so as�o become sublec�to the Workers'Compensarion laws. owNea � CO.iMP.NO. JOB NO. �tlt¢ Applicant ADDRE55 Q I� iRUNN VEiEMIT Np. ROAO YEkMIT NO. NOTICE TO APPLICANT: If, aftar making 1h15 �B�(i{iCdtB Of CITY TEL.NO. AFfipAVli WAiVER EASFNENi REGORD INSTR.NO. �AiE � ���mption, you should bacome subject l0 1he Warke�s' iE�Ai �pensation provisions of�he Labor code,you must forthwith .oesceivrioN ioT No. �' nwv.oa sT.wioer+in�c comply with such provisions or this permit shall be deemed IBVOItB(�. BIOCK tRACi STAiE ENCROACHMEM LICENSED CONTRACTORS DfiCLARATION �.dF BLDGS °faNaT uo. SIZE OF�O� NO'N ON LOi I he�e6y affirm that I am licensed under provisions of Chap�er �5E o� D(commenting wiih Se:lion 7000J of Division 3 of Ihe BuSi- BWLDINGS cHnrs�[5 ness ond Professions Code,ond my license is in full force and EFfBCf. -���` CONTRACTOR CONNEC�ION CHARGE fEE License Numbar�a�lllj�Lic.Closs ADDitE55 �/ -RriMauRSE+HENr FEF � q COnifOttO�r._,�fe � ^4{J�,,,,Q. ��SiRiCiNO. GROUP MAP PROCESSEDBV V CITV TEL.Np. /�7 /7 SiniE ��� BK iG ❑1 om exempt vnder Sec. of e L.A.Co. uceNse No. � � aas5 � � R � Plumbing Code and/or Sec. of the No. DESCRIv7�ON OF wORK F�e F��� " " �- � Nous�s�wea eoNwee*wc ro nnre VALIpAT10N � 0.&V.Code for the following reason � ou6�ic SEweR ? �a-7-j �� � IC tANK,SE PItGF PIT OR FINAL Da}e PIiS ANA/OR ORAIMFIf1D gY � � FqUSi SEVlfk COM1NJICTING TO � VPIVATE ql SYSTEM $i JlIOfUlB C�NNECi ADDIiIONAL BI�G�OR � OWNER-BUIIpER�ECLARATION woRc ro Nous[s�wae OYERFIQW SEE AGE PI DRAINFIELO I hereby affirm thal I am exempt from the Contractor's License ExrN.,c L o6�vWEtL MnNNOLE Low for the follawing reason(Secton 7031.5,Buisness and Pro- aiT x,REan,a oa abAn�lou MpusE � �i0n5 COC{BJ: SEWEF OR OISPOSM SYSTEM ,_, I,os owner of ihe property,or my employees with woges as �1 ���9 F their sole compensation,will do the work and the struclure � is not intended or offered for sole(Secfion 70�4,Business �� and Grofassions Code). OWNER"5 Permit S � �` • ° ° •� � ❑I,as owner of the property,am exclusively tontraciing with AUTH�R�ZATIDN TOTAL FEE � • s'��,5� li<ensed comractore�o construd the projecl(Secfion��44, �HAVE Ai THiS OATE A CONTRACt WITH THE HEREIN NAME�CONTFACtOR i0 Bl13ifIC55 OII(J P�OfB55i0�5 CO(i2�. CONNECf iH[A90VE�ESCR�OE�EXISiING DWEIIING TO THE PVBL�C SEWEF. � �. c)�,G n` ! JV CONSTRUCTION LENDING AC�ENCY SIGNEDTHIS DAYOF 19_ I hereby affirm that ihere is a construction lending agency p�yNER ox �2,��—8 Q for ihe performonce of fhe work for which fhis permit is OwNEaSnG[r�r issued(Sec.3097,Cir.C.). � r e� n�_l nooaess l nder's Name_L„��L��E j r�, ��a•5 Aa�'e�/+—.S.a11�.�s:�;��,��O�g 3 I certify that I hava reod th� appl�mtio on s�aro that t e a6ove informotion is[orrotl.I ogree to comply with all County ordinances and S�oro law reg�lating Plombing and Sewe+s, and her 6y authorize re 6 en�atives of Ihis County io enfer upo �above-mention -perty for inspecfion purposec, / .�J — Siflrtafure of er t ate SEf NtVERfl fOR EX►lANA70RY MNOUAGE ... . , `L� T.. � - L.. 1 . ti' • '� _ �r � ����_• • _..__. . .""'_ '._ . __.._'��--_ . '�y'i•. e:� (!e�'RI�:R—�!1i.f�$��'�L�1o�'L� +� ��.-� �i ..�+..���.�s..s..+�rw.sa.. _ ..._ _._.__.—__._—_ .. . . . ... -�_A.�►=��wi+,�t-i , . -'. °• T� ,� , � � ....�.-'��.�+�'�'�"..- ..�.� _ . . .. .._ .. _. . 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