Loading...
HomeMy WebLinkAbout0891A - --- . __,.._---- _. WORKERS'COMVENSATION DECLARAi1�N , ' � 1 bereby offirm tha� I have a certificate of canseN lo self �, �, . }I insuro,or o ceniFiwte of Workeri Compenw�ion Insurance,or �aab�xo . u a certlfiad copy theroof(Sec.3800,La >���IRUT CEBGBIREV.1/BJi APPLICATION FOR PERMIT Polic Company __—_ _ - ❑c�.f+�oP hereby f�rn�shed. SEWER - SEWAGE DISPOSAL I�Certified copy i:filed wi�h the covny building ioap«tion COUNTY OF LOS ANGELES BUILOING AND SAfETIf . depar me �. Dote���Appl�cant' S� fOR APPLICANT TO FILL IN }-S I . CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' eunox+c /`' y COMPENSATION iNSURANGE �oat�ss 2 o S66 �"� (,,,F[k G�i+' C 7• S1ATIpJ L -� oFarH /� (This section need not be completed if the work involved by the IMNlKKF FFFEHNCE . ��� pe�mil is for one hundred dollors(5�0�)or less.) �OC��TY G/�Q � I cerlify Ihot in Iha performonce of the work for which fhis p5,55T_ Y rrv[acor+r+[crioro ur�THFRpN, �CUR! i.4 M.l.TO P.l. permii is iuued,I shotl nor amploy ony person in any manner � so os ro become subject to the Workers'Compenwtio�Laws. oW�R f f1.� v"��"O� ,j a co.uv,v.r�o. �oe ra. Dote Applicant nDORESi rO. �� iRUNK PERMIT NO.� ROAU RRMIT NO. NOTICE TO APPLICANT: If, atter moking �his Cert�fim�e of �iT� AffiOAVrt wnivea EASEMFNT RECORD.INSiR.NO. WTE Exemp�ion, yo� shoold become subjec� to the waka.- �+ TE�.No. i -G G 0 Com nsoiion rovisioas of the Labor code, ou must fo�thwith pESCR PiION , ioT r+o. Pe P Y nwr.oa Sr.w�oEN�r�G mmply wi�h soch provisions or this permir sholl be deemed � fevOkpt). BIOCK TRA[t ��� SiAT NCROACHMEN7 IIGENSED CONTRACTORS DECLARATION rao.a�o�s. � ^�" �''O� I hareby offirm�har I am licensed onde�provisions of Chop�x sizeovior r�oworaior � us�or 9(commencing wifh Setlioa 7000)of Division 3 of Ihe BuEi- " eunov�Gs cH�ac,[5 ness and Professions Code,and my lita�se is in ful�force ond effect. tor�+txnaoR k e.y CONIJECfION CHARGE FEE license Nomb � , ' hS�tit.Claac � AODWE55 ' ' YF�MBURSfMENi e ! �" o�sraKr no. cao�o n�,�v tsseo er b com,a«o, — oo�� i/ � y • f �-- �ITY lEl.NO � U ❑I am eKempt under Sec. of ihe L.A.Co. iic[Nse h�0 cu55 '3 L LC' �'�- [4�at3�� `'a Plumbing Code ond/o�Sec. of tha N°_ pESCRiPiiOr�a wORK r�E r�ti�i . . O �aus�s�v,Ex cowacr��ro � DATE � VAUDATION w B.8 P.Code for the followcng reoson ��«�R �� � �Z^�'�J � rri iMIK.SEEP� vrt ow R75 AND�OR ORAMFlEI� ' �A� N Dote Fp��$E yyhp Cp�tECTING TO Br 2 PkIYA � Siqnorure co.+.ncr�ao�rio"u aioc.on ' �0 8 9.1 A OWNER-BUIIDERDECLARATION ' ��'����'''�P OVfRfI EPAOE PIT,DFAMFIElO I hereby affirm that I om exemp�from the Controcior's Liceme txrN_c[ssvooi oxrweu In...Nr�o�¢ ��. e • • � p Law for the following reawn(Setron 7031.5,Buieneu and Pro- x*ea,xenn�p oa wser+oow wuse � fessio�s Code): s[wen on asrosu srsrtm . � ❑I,ns owner of tha property,or my amployeea wifh wagea os � �� ` �2�.5� their wle compenwrion,will do the work oad the stroUure �, • • •r 7.,�j�'� ia not in�ended or offered for wle(Seciion 7044,Bosiness � ond Profess�ons Code). OWNER'S Fermif S / �� � �,�2—8 5 ❑I,os owner of the property,am e�clusively controcting w�th AUTHORI2ATION jQTAI FEE 7 s'D lite�sed con�roUors to conzrruU the project(Seciion 7W4, I MAVE Ai THIS DATE A CONTRAC7 WIiH TIiE MEREIN NAMfD CONTRACT04 TO BusinoZf pnd PrOfeSiIOnS COdlJ. CONNECT iHE A80VE DESCRIBED Ex15iiNG UWELL�NG TO 1Hf PUOIiC 5[NTN. . CONSTRUCTION IENDING AGENCY ' , '�. � , 1 hereby offirm thot there is a mnstr�ciion lend�ng ogenty ��EDil115 DnvOi l9_ for fhe parfo�mante o1 the work fw which this permit is °N'��R OR �. � ' Issued(Sec.3097,Civ.C.). n ow�as�tar lender's Name_��H AODOE55 Lender•s Address �. 1 ceAify Ihal I hnve read �his applicotion and stale tlqt the � � above information is wrrecl.I opree ro comply wi�h oil Counry �, wd�nonces and Stote laws regutating Plumbing and Sewera, � ond heroby aulhorize reprosemativea of ihis Couo�y�o en�er � . � �pon tbe above-menlioned property for inspection purposes. � . {/.P T�/��i�oa� /�-.��-�� ; Sign �e of Parmi� Qa!e i[!REVERSE FOR E%rIANAiORY LANGUAGF ' _ _. _ . . . ,. . � . �;< : __ _ ;.:, , . ��LF�CTO�'SF:'JTCS �, "� O��i.i:�:-i;i�l�.nr r,n�:ri,;v;�,�t►c» ��--L F �6Vf.L5 c r � F's V s s c i,7.uw,�.. --� ..-- _—_. � . . ,.� , ". �ir � th�S t t ct��., . .. __— .__...__.__ .____. � 1 F--I� t r t t 1 i i �l r.[vn c�..:,r� _ � l.�c.n 1 1 i� I r th Inflm in�, rc.r r (-ru o �l 1� � �.-.� ......� �, .. . . �� . . f, � . � _. . . C r � . ._..� . _ . � .. � ! re r+.,� r�ev t trr( lr.r�� u . "i, !` or �.:- c �,.: . .. .i .__. . ..__�. .. ,.,.�� . . . ._� .. ..-..- . .. _ i ..'T�c a c r, ' ' ' __ ._,_ _ ---_ _ _._—__ ',rrf .nii o:rt fi.re.(r�r t�«�itisunri cl.n ri q� r< t:rr �_r.o�o.r.� �ru....�.-.... _ '_ �.: . ,'_ _-�' � � . . _.__.. _ ..___:.'_ _...' . .._ _ _ . . .._. . ... ,�.Lr< :'!6• r�G� i1(��Jlc} rds7iCr.�ii't,-c hei� , ' ��•� �-� = N[._�. • ..��. . '., . ' �__.' -__� ____---___-_ . . � _ '__.— , ' � fi� r�r� r ur,� t f 11 f r rr a ns'!4� C'nrr:rn^!n�'s ....-. �.. . . . '. ' .�,. ' ' -. . . '.r ' �.'. . . �. Lr ui.c L�n, I(f�.r,1u�.(r n�wui.;�H�rtl:.Lati�in iu'!fq nf _ _. �.'Eo � E o: � �' ` _____ � .._._._��_.r__'_'._�'__ � n.fnJ(h l .�ir�:ssrrdl�rnf�vci��. l.rleiri-Mrt:h:is ....v' .c.� ....,i�... ... . . _. ._ . .__ _—.__�._..____- . . 9Jiri� . . ., . . . ..- .- ., ��. r_ .r d<r j� �n. t rt t�<n',(�,r U rt�,��r � �r �ri. � :�cC., i. . .— .. : � .- ' ;1rl�rufa.i�i�rn Sr�1�✓rr72i7.$hr�)n a� 4.nr1 - _i: . ..�+s .:.�..:.:........�.: ._. .._. ..-- - '- �` � _. . f . � 1 f,.�r/.rr _ -.,:�r •, ,, .-_� . . . __ . - - . � . . . . .. . +�h�;�b Ui<�n„du mu!��a cn��f p�rrnl.r rJ no��r�re U�r.n fi . � rc .... �..�fl �,.� :.�y:-."_: . .. _ . . ... ._. . - �: .___—_." ___. ._�`-.___'____� � li�mdad drl(r.ic I}�Gp�� � � .. . . . . . : . : . .� .. . � (��I.a�thr uw ncr uC thc t���ill Ju Ihr nrr6,and � ....__. __ . . .. � . .,�., _ pn�prr . . _..._ _ _ ._... - . . _. . .__. ..-._ . .� •, . . . . . .. _. - . [h:ctrcchrrr is nnc intcndrd m ntL rrd fc•r�al:. . -_�� � �� ' ' . . ' . . _ . ..- _. . . -�� . .. �(.Scr�,"�1J.f,icsi�n as�n:11'rr f�cinm('m+r:7 Ar('nrur 1ri=`c� . ,. . . . ... . _. .. .�.. . . ... .., � ... ."..__-_ _. ___._.__ _.... _. . .�_ .. . _ . . . .. .. � � � . . l.rrncc I.mr�da:r�inf nprlr ta r.ar nvnu.nl�,rnp -,�'��i:n' ' , ' _—'�'��— _. . . — _ _... __ _ _. __ _. r� �r,,���.;,,, �„u�s„�»..,-,�,t„i,,,�s <«.�n,,�,Anr„•„•rj . ._._. .__...__ .____ .... ._.. . :� • .._ ' •� rn�nidedth«rs��ilimrprn�� uleurrrr��ti�rtud:�,�nr�flrrd - � . . ��—_�_-;--__. ' . . � . � -- . . � - .fnr vilr..lL 7rn:cvrr.U.c 7,�.�/JJ,','ai ir:rvuiurun rs.�u(d . _ _._._ ... . . . _ . . � � . . :.`... � ,. � '�. ., '� � _��_�__--..__—__._.—___._.___.___.____ ' ���fhian,�.irnr�J��un�phrron,�hrn��mrlm,l:�rwrllhnn U:r, .' ._- -__. _. .._. .�. . ... . ` � - `- ' .� ..: . . ....- . .. .—_ .. , , . - . � -' _ _ . hu�d<�n.uf prc�n.,;t;u(Lr drc�r.o!Fuild ni iu�prorc frr,lGr ._. _ . _., ___._ .. . _.__. . �� ��. ��-- - �..� .... _ .. '.. . p. prrenf,�a(..) � .�� ' � . . �, � ----. __ _ . __ . _. .: _ ,_ �._ i:irn ezcmpf undcr titc:_----------� � -' _ � . . �--_—__-- .— it 1�:P.(:. fur tliis rea�on -- -- - ---- � _ .� � _ _ _ _ , — --�-•—�---- . , .. _ ___.. . _ _ __ [?:ttr_ I ----- � .._ ..._. O�rncr---- — -------- -- -------- -- -- - - --.. i^�sr[aoc`s��oTes �