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HomeMy WebLinkAbout1773A �I-N D�CI,CRATION � I Mreby offirm �hat I have a ce.tificafa of consrnt ro eelf �nswe,or a eertiiica�e of W«k�ere'Compensarion Insuranee,or ieneszo ;�I �N-���a��°b`�'�� `��1Re0193i APPUCATION F4R PERMIT � ❑Ceriified copy is hare6y furnished. SEWER • SEWAGE DISPOSAL ❑Cenified copy�s filed wiih the coun�y bui�ding inspecUon COUNTY OF LOS ANGELES BUILDING AND SAFE?Y deparfinenl �f —_ I Dme Applicant7�H—�d� C_F}rQot.Y'1 FOR APPUCANT TO Fill IN CONNKTION DATA CER FICATE OF EXEMPTION FROM WORKERS'`�- auimiNc t a COMPENSATION INSURANCE aoor�ss srntroN oEvrH (This section naed not be compleled if the work imolved 6y the iaqiitY nnnN�+a[aeveReNce °�R permit is for one hundrod dol�ars(5100)or lass.) 1 certify rhar in rhe performance ot�he work for which this fRp�Sgr TYMOFCDNNECTION ��rHp� permil is Issued,I shall nal employ any person in any manner �� CUrte P.t. m.i to P.t. so as to become sobjeci 7o the Workers'Compensation LOwS. pWNfF . �� CO.iMP.NO. JOB NO. ��� TRUNK PERA1it NO. ROAO PERMIT NO. ❑ate Applicant Aooaess ) NO710E TO APPLICANT� If, af�er mak�ng �h15 Cerf�ficnte O{ CITY � TEI.NO. / +��ty AFfIpAYli WAIVER EASEMENi RKORO.INSiR.NO. OAiE � �-nprioq you should become s�biect +o the Worke�i iE�Ai 1� ipenwtion provisions of the Labor code,you must forihwiih pfSCRiPiION ior No. '►� ^i� Hwv.oaST.wioeNiN� comply wifh sucM pravVsions or ihis permit shall be deemed (� revol�BtJ. BIOCK TFACi {/ STAiE ENCROACHN.fNi � LICENSED CONTHACTORS DECLARATION na.ov eiocs, �R'"i'"'o. s¢E or ior Now or�ior I hereby affirm fhal I am Ikensed vnder provisions of Chapfer u5E OF 9(commencing with Sedion 7000)of Division 3 of the Bvsi-� eunowcs cHnrtGes ness and Profyssions Code,and my license is in full force ond CffeCt. �g �`Q�� CONTRACTOF CONNKTipry CHARGE FEE LiCEnSe Num6er J7l J W (i[.CIa55 pDDRE55 �REiMBVRSEMENt FEE � COnflOCfOr -,7ri� girS�♦e OtY TEl.NO � ' DISTRICT NO. GROUP BK MAP � VROCFSSE�BY u ❑I om eaemp�under See. of the L.A.Co. iieeNse No. c nss � Plumbing Code and/or Sec. of Ihe NO. DESCRIPTION OF WORK FEE FiNqt V 'ause sewcr cor+necrwc ro � o�re � a p � VAllpATION a B.&P.Code for the following reason vueuc sewee ft TANK. �k O h VIiS AlypiOR A�NFI FlNAL '� Dpte NOUSE SFWFi C6N tING TO B� GR�V4iE DI SYSTC.M "- Si9nGtU�B CONNFCi A�OiiIONAI&DG.OW � � OWNER-BUIIDER DECIARATION wor+«ro Noust sewee WERFIOW SEC�AGE V17,DRAiN�IELD 1 hereby affirm that 1 om exempt from fhe Controcior's License Exrn.,CE55rOot,oavwEu.MaNNoie low for�he following reoson(SCctOn)O31.S,BViS�055 pOCI Pf0- A�1'ER,REPAIk O aar�naor�nouse n 'ons Cotle): SEWER OR DISPOS0.l5N5TEM "I,as owner of tha property,or my employees with woges as �heir sale compensation,will do�he work and the slructure is not intended or offered for sale(Sedion 7044,Business and Professions Code2. OWNER'S PB�I1li1 E �� � �� 7�•3� ❑I,as awner of the property,am exclusively comracting wirh AUTHORl2ATION TOFAI.FEE - �;,� . a�• � (� licensed COlI�fOCf0�5 f0 CO�51(UC��MC PfO�EC��SBCfiOl1�O4A, 1 HAVE At iH15 DAfE A CONIRA:,T WItH iHE HEREIN NAMfD CONTRACi F TO ) /� BUSIY1855 4lICI P�OfE5510�5 COd2�. CONNEC7 iNE ABOVE OCSCW�BFJ E%�S1�NG DWEILING i0 iME PJBI�C SEWER. � ^ r 2 (.v" CpN57RUC710N LENDING AGENCY $IGNEDTHIS �AYOF 19_ e e x I hereby offirm that �here is a consfrut�ion lending agency � � G !,�;:�o for the perfo�mance of the work tor which this parmit is Owr+eeoa c issued(Sec.3097^,C_iv,C'.J — + owNEas nceNT L�2 2�;'-E 4 L�ende�s Nam�e,q��-[�,�1j�'^fnC'i1Y�� __L_��. y Aooa[ss Lender'P,�ess�'[(.� • �1�E �IX'�(�a ��r3 1 certify that 1 hove reod this oppli ion nd aoote fhnt Ihe abovs iniormolion i�torrxt.I ogree to comply with all County wdinonces nnd State laws regularing Numbing and Sewers, and haraby ou�Morize r �esenkHives of�his Counry to ente� upo� oboW-msn 0 prDpery for inspecfion porposes. � `�i $ignnfura Rer ss DaFe SEERFVR3E►OREXRANATQMLANGUA6! - -- --_ _ _ __.__ - -------_.� , ,��.:�`...; ��.. �-�.. ,�..'�'"" � �:., __ ___— n����:�-�1�.�R�s�cL.t�r�r� , -.�y - ..,�. ,r;r��e .¢-. y . .. ..... ... . .. . __.. . .. f lm,�rK::�.Rllvut lh�A 1 ure u.awpl fl-o.n tire G»ih-:R•N�'s . . l _._ . ._ ____..__ . _ __._. 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