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HomeMy WebLinkAbout1771A kA�T10N I hersby oifirm tha� I have c certiflcote o(cortsent�o smlf insvre,w a certi5icaa o€Wo�kme'Compertsotion Insorance,w �eAoa�o o f o t e Lob ) ``B°g`R`�"a" ApPtICATIt�N FOR P�RMIT � P�y'1�. ` - o pan� A' ❑Carrified copy��hereby fumished. SEWER • SEWAGE DISPQSAL ❑Cerrified copy�s f+led with the roonty building�nspec�ion COUNTY OP LOS ANGEIES BUILDING ANO SAFETY de�p7arimert �Q � �} oaie�C��Applicant_7L'� L��YB- FOR APPLICANT TO FIEL IN CONhECT10N DA7A CERT ICATE Of EXEMPTION FROM WORKEHS' euuoir�c COMPfN3ATION INSURANCE aoore�ss �SranoN oErrN (This sect�on need nar be campleted if the work invol�ed by�he i�iirY n�wrvHoi[aereRer� ��R permi�is for one hundred dollors�f100)or Issa.) �A�Sr tvvEOFcoNNECtiOrv �r.�cptHrRpM I cenify rha� in �he performance of the work for whith this 'ceasssr. v. cuke v.�. m.i.tOv.t. permil is issued,1 shall nof employ any person in any monner ao os fo become sub ect to fhe Workers'Com ensolion L4W3. P.C.NO. I P OWNER CO.IMP.NO. lOB NO. DatB Applicant AODRESS � TRUNKPEPMIiND. ROADOERMIiNO. NOTICE 70 APPLICANi: If, after mokin Ihfs Certificate of �/ nvvioavrt WANER easer�ar aemao.iNSTR.rao. o.re 9 CITY �EL.NO. "� .7 9 - �"mption, you should become subjecr io rhe WO�kers� IEGAL .ipensofion provisions of rhe labor code,you must fa��hwilh �oescz:vnoH iot No. � hwv.oa 5T.wiocwNG comply with s�ch provis�ons or this pe�mit ahall be deemed 9� �evaked. aiocK iRACT � J $iAiEENCROFCHMfNi LICENSED CONTRACTORS DECCARATION ra.oF atocs. �RM�T�'1O. S�ZE OF l0� NOW ON L01 1 hereby offirm tboi I om licansed under pro�isions of Chapter usc oc 9(commencing wirh Seciion 7000)of Di�ivon 3 of+he Busi- guaoiNcs " n+nrtces ness and Professions Code,and my licanse is in full fwce and C{fCCt. ���^�� CONiRACTOR CONNECiION CHARGE FEE LicenseNumber�,f(ij(,JSL—Lic.Class � p � -REiMe R �*FEE Y aoozess 4 Cont�aGlOf����tE�� � 'A�, �� �ISTRI�iNO. GRDUP MqP PROCFSSFOBY � CIiV TEl N0. v v SiAtE UC. �Q � vG 'O ❑I om exempf under$ec. of fhe LA.Co. u�eNSt r+o. G�ass PlumbingCadeond/orSsc. offhe N�� DESCRIPIONOFWOFK rEE Fwal � PUBt C$EVJER CONNECTING 10 � JAtE ^� �/ p i/ VALIDATION � B,8 P.Code for the folbwing�easo❑ � o T SE IC TANk 5[E4AG[i1T O w Date PItS AHA/OR DRAINf lp 0Y A� � HOUSE SEWER CONNriCiING TO �, PkiVATE DIS SYS,*EM Signature CONNKT AOCIi�ONA(BfUG.OR �� OWNER-9UILDER D€CLARATION 'tiDm�To HousF SF'aFR I hareby affirm thm I om eaempt irom the Contranoi s Licanse �irv���issrooiGoarweRA�nuvHoie Law far the following reason(Sedon 7O3I.S,BUISOBSS Ond Prp- P1iER,REPAIR Ok ABAtr60N HOl15E �0�5 COdB�: SEWEF Ok Di5IO5AL SYSiEM, u I,os owner of the property,or my emplayeas wifh wages as � their sale compensafion,will do the work ond tha srrut�ure is not intended or offered for sala(Section 7044,8usiness and Professions Code). OWNER'S Pefmit S �� a°�� 7�.� P� ❑I,es owner af the propeny,am ezdusWely controcti�g with AUTHORIIATI�M TQTAL fEE � ].i�.• . . . }(} �kensed mMro<tors to mnsfruc�the projec�(Seclion 7044, i HAVE Ai rws onie n mNra�cr wirq rMe nee€�r�r+ti�o coNr�ncr e ro Bu5i�255 tlnfl P�OfC45i0I15 CO(IC�. CONNECT iNE ABJVE MSCftigED FXISiING OWEILING 10�ME PU&�C SEWFR. � t' •2 7.5 p CONSiRUCT10N LEN�ING AGENCY SIGNEDTN�S DAYOf 1G_ I hereby offirm fhot fhere is a consiructioo lending agency � �- h G l,J',J�i for fhe performance oF the wo�k for which lhis parmif is owH[aoa issued(See.3097,Civ.C.. owHevs nr,eNr �2.2 t�-s u Lendai s Npme „��__ ^ooRcss ����,�d�5 I carrify thof I hava rao rhis op ic, �on and s�o�e�ho�the ubave info.motion is carxt.1 ogres�o comply wi�h all Counry ordinoncea and Sto�s ws regulofinq Plumbing and Sewers, ond hereby outhorize preasrrfofives of Ihis Counly 10 enier u -e abore-rw�rw praperty fa�napection purposss. 1 �- i vro 'W ��iee Dole� SE!R@VER3F PO�BX►kANATORY IANOUAB[ --- --� ___ --. _.,._._ ___ ___ ��_ _ _ . "�" ^ (}14'YA:R-�'f.'E�.L���E:Ct.AR:!?�d'�F F _ _ -:�a ...� s-.n �� ------ — :o-.s .� � +-�; i ,..w��+-.st�.r.-w � ... ... ... . 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