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HomeMy WebLinkAbout10185 _-__---_——— -- _ ----- - __._ _ ._. . .._. _— --_._..:_. ._ . . _.__.._. ._.. ____....._ _._ _. . yl-� . __. ._ .._.. ._._.. I_ WORKERS'COMPENSATION DECLARATION q=_pppp DPW 8�8] - I�hereby affirm that � have a ce�tificate of consent�ro self�� l��zD � � . a'l�sure,or a cenifimte of Workers'Compensation Insorante,or �E BOB �e�,�f�ea�oPY,he�eo'�Se�.'e°°,�°�b��.�, � ����� APPUCATION FfJR PERMIT Polity No�mP�^Y___;a.:_�3�?--T-� , �s. . . . ., . �ce�rr�ea�oPY�s he�e6Y r����5hea. ; , � SEWER�- 5EWAGE DISPOSAL „ - ❑Certified copy is tiled wit the couroy build�ng��sPecroo CQUNTY OF LOS ANGELES ' ' BUILDING`.AND SAFETY, ' " "` . I , d�ep�ar.tm�e�nL����q-� . � •��� � Dm�Applicani� ���"�� FOR APPLICANT TO FILL IN'' ' CONNECTION DATA CERiIFICATE OF EXEMPTIO ROM WORKE 5' euitoiNc ' � � �, ' ' COMPENSATION INSURANCE � -� ��� nooaess SiATiON DFviM � (This sec�ion need not be completad if the'work involved by the ' � � � ' ' i,wN�qie a¢FtaeNte � ' � ,� ' i u°°e° 'permit is for one hundred dollars(E100)or less.) ! tO[nu7v . . . iowtu MARfSi � , � TYVEOFCONNECfIpN I certify�hm in�he performance of�he�work for whicb this caoss sr. '� ' � � - - r. cuas : v.� I � .'�.r�aiGio r oM � �' pe�mit is issued,I shall nof employ ony per5on in ony mpnner � , � . �p.C.No. sa as to become subject to the Workeri Compensa�ion Laws. �NEq ' ' �O.IMP.NO. JOB NO. D ' i � .,, MAIL n yO ' 7RVNK PERMIT NO. � ' �� ��.�ROAD FERMIT NO.'; Da�e Applimnl �. �.. nooa[55 Idy / , _ . • �. �� �. �.. �. . � . NOTICE TO APPUCANT: If� Of�Cf mokin ihis�Certificole O{ / n�/� Affi0AV11 WAIVER EASEMENT NECORD.INSTR.NO OAiE 9 CITY TEl.NO (p /-7 ���emption, you should become s�bject to Ihe Workers' iECA� ' � , �. ^pensation provisions of the Labor code,you must forthwith DESCRICiION iorNo. / MWY.OR57.WiDENING � ,eply with suth provisions or Ihis permit shall be deemed � , ' lEVOkO(I. � � � � Bl0[K TRACT SfAiE ENCNOACHMEN7� � - � �NO.Oi BlDGS. � / � PEGMii NO. UCENSEDCONTRACTORSDECLARATION, sizeoFior r�owaaior / �� '� � , �- � �I hereby af(irm�hat I am licensed under provisions of Chapter us�OF � �� �' 9(cammencing wilh SeUion 7000)af Division'3 of thelBusi- BuitDiNGS WakGeS ��ness and Professians Code,and my licen3e'is in full�foice and � , �. I �� CONNECI�ON CHARGE fEE } eHecL ` � mrvteactoa P/ �b� ' � � pEIMBURSENENTFEE ' � a � �License Nomber Q Lic.Closs� aoouess (r d� V ' COf11laC�Ol f/�� �OOte L �J CITV TEL.N � DISTRICi NO. GROUP MAP;� PROCESSED BY STAfE llC. BK �G�- Z ❑I om exempt onder Sec. of the LA.Co. uceNse No- ctass �� ' l� . � O � PlVfiiUiflJCOdeGnfl/OfSCC. OfIFIC � NO. HIPTIONOFWORK � FEE ' . w fiNA� HOUSE SEWEF GONNECTING TO oA�E I '�VALIDATION . B.&P.Code for the following�eoson M1BliC5EWER � �p-[L+- � �. . , � a . I-- ^, f�Q $EGfi�iANK,SEEVAGE Pli OR y � Da}Bv����/O� PiT5AN0/ORDRAINFIElO BYAL � ' Z �, HOVSE SEWER CONNECTING f0 C o ' (�,.,/'�/ ORiVA7E OISPOSAL SYSiFM �()5 Z('A � $19f1p}UfQ � �•' �� CONNEC�A��IiIONAL BLOG.OR �. ' � � � �N1NER•BUILDER ECLARATION � �K ro Nouse s[wev. � �, � OVERFLOW$EEVAGE Vli,DNAINflElO ' . �� � • • 1 O , I hereby affirm that I am exempt from�the CororoUor's License exru.,cFssvoa,oawrtu.MnNna[ �. �Low for Ihe following reason(Secton 7031.5�BUi5I1C55 Qlld Pro- ALiER,REVAIR OR A6ANOON NOUSE � �� � � � � � �PLSjOf19 CO(�2�: SEWER OR DISVOSAL SVSIEM .� � ..� � � ,� • �?7.5 Q I � 1,as owner of the properly,or my employees with wages as _ � � • � •'?']rj�S ', their sole compensarion,will do the work and the:trucrore . _, '�, ' ' is not intended or offered for sale(Section 7044,8usiness � 0�Q 7_�y Q and Profess�ons Code). OWNER'S Permit S 0 ; � �I,as owner of the property,am ezclusively coniracting with AUTHORIZATION TOTAL FEE . �I licensed mntraUors ta tonstrutl the PfOj2C1(SeC1iOn 7O4d, �HqyE AT iH15 DAiE A CONTRAC7 WITH THE HEREIN NAMED,C�N'RnClOti IO . ' BUSif1E55 Of1d PlOfB5510�5 COC�E�. CONNER TME ABOVE DESCRIBED EXISTING�'NEILING TO TME VUBLIC SEWFR. , . , �' CONSTRUCiION LENDING AGENCY .-y�— '� �� . � , . � , . . � I he�eby affirm Ihot there is a [onslru[tion lending ogency SIGNEDTHIS ����^"OAVOF �. for Ihe performance of ihe work ior which this permif is o`�NEa ou f ���. Issued(Sec 3097,Civ.C.). . ' owrveasnctNr � ! . ��� i qDDRE55 � , '� lender's Name i- -�Al2� � � � � Lendei s Address ���'r.i� �4 �7 � � �� I I , I certify that I have read this oppl�catio •and staie that the ����/ �� ' a6ove informo�ion is correcL I agree fo'comply wilh all Counly , � . . , ... ... ., �. ardinances ond S�ale laws regulating Plumbing and Sewers, � , � � and hereby authorize represeNatives of this County�o enter - � � � upon�he ahove-mentioned property fo�inspeUion purposes. � , ', � � � '�, ' �� � . �� "/ �tif+ti� o-T�2�� _ Si �re of � Date SEE REVERSE FOR E%PLANAiORY LANGUAGE �, tHs►ecroR�s raores ,_.: _QWNER-DUILDER DEC�:�t'�;fION APPROVAlS on� wsr[aat's s�c�ntur.e I hcrehy a$irm thnt I am ezeatpt[ton thc Conttsttor's t+cw taose scw[a I � - � � License Law for the foiloa•ing re2.^.on(Sectior,7032.5, I b�b� Basinrss.ond ProJessior.s Codv/� dny �'1ey or munty � eorv�+ectnooinorau � - �-whieh-regutres a pen;ii! to eanstrue!i.a(lsr,-improve, � aenow�oa wOaK - �� ' - �demolisL,o�rrpair nay siruuurc,j�ri�r to its iss�:anre, SEPi1C TANK 3EEP.VIi($I rwoioa oa.ainviem � � —.,c.,�� ako regaires tLe a�plican[/or sucb ycnyit ta frJe a � eess000:❑ ear+rt«❑ ` � siqned swre,nene:Got i,c is l�censed j•ursuant ro sbe � provisians oJ tbc Contrcctor's f.iccnsc Lnm(CLapter 9 I-1TER,REPAI2,SEYhR OR (cornmencing urtb Sectinn 7000)aJ Di:•i.rion j C�1)JC t 5tvn.cearsro5nt5r5rtrn .. „ � _ Busmeu end Professions CadeJ or tLat fiAi:exenrpt� � WSCONMR PLUG ANp � � ABANDON HOUSE$fWER � '`� tbereJro+n and tGc besis Jor tGe ollrged esem/�tion.Any � s.,cKrn�scrucuuKs❑ � �' �-- �� � . imoiationojSeclion7o3t.5byanynppl�careJarapermit I :eev,vrt{57 O assvOotS❑ - su6jects tbe¢pplicar.t to a civil penalty of not rnore tban I ' , , , . _ .\ '; 1. � fise�v�dred do!lurs(S500J.: I � ❑I,ns the ov.�ner of the property will do tFte w-ork,and ` �the strueture is not intcnd�cr uffcred for sa]c. (See 7034,Tiusiness and Professior,s Code:Tb¢C� ' � - � - - Iractar's Licrnse I.aa•does r.ot aprly to r.n aamer y , � � "- property a•bo buiWs or improvc:ebereor.,nnd u+Lo dnes � � � � • aucb work bim.se(J prorided 11 a:sccb'imf,rorernenit ' .- .. .._. . .. . . . . ' arr not intrndrJ or nffere-�Jor sale.If,bo¢�cvm, tGe . . . . . . ' . � � - ' duilding or imfirovement is sold�cit1%n ome ye¢r aJ � - . " ,- romplet�on, sbe oa�ncrvbu(d u'l:ba�c tuc burden � � of p oai►p tbct hc d'ut nnt lryld�or�Snprovc for the� pu pase of sale.)� � ` , ''�} `-�1 acn e�empt undci Sec. , ! �� f 8&P.C.fo:this re�eson ; i -,_ _ � , Datc ; Oamez � ; � � ` IP35Pf{TQR'S N07ES . . . � . . . , 1 - . . � .. . . . . . . . . . , . , I .. . , . .._._ . . . . .. . i . �'l: � \ \.v,_ , .. . . . , . . � , -�. �. . .... \ . .. .. �. . , .,. . . -��\� . . - . � -. ... j-- - , ... � . - ,. .