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HomeMy WebLinkAbout1227A i ..� " � ORKERS'COMPEN5ATION DECLARATION. �.:. . . � .� .� �� .. � � . � . � � �. i � � i�hareby affiim that I have-�a certificpte�of consent.to setf , � �., � , _„�.� , , ' '„ � - ����. . ' � 76AWZD `� . , '.'� . .. . i insure,ot c urtificote of Workeri Compen¢otipn Insuronep,pr . , � � � � a certlfied cppy thereof{Sec..3800,tab C;)��. . - cE eoe IR¢v.aiei I �;� '.�. . I Po�,�y No. �,mP,�Y �„ APPLICATIUN �4R PERMIT �c��rf�ea�oav;:ne�ebY+,,,�isnea. �- SfWER �i'�,EWAGE pISP45AL' � � �❑Certified wpy is tiled w�eh the eo�n�y butldi�g��nspect�on . �. . �.�. :COUNTY OF LOS ANGELES �. '�� . �-$UILDING AND SAPETY -����� - -��I�, . � ���deporlment, . . . . Dare APplicant -FOR APPLICANT TO F14L IN `' ' CONNECTION DATA I ' � - ,-CERTIFICATE OF EXEMPTION FROM WORKERS' - .� . � � � . �� . � . � � �-� COMPENSATIONlNSURANCE - � � � n�ooReSs� Stqiiow� f.��? ���:o[vra 1�� �� (ihis section naed not be complered if the�wark Invo�ved by t6e � � � , �� mnHHo�E Rer�aence-. .�/dg.:� .'�t� �- �o,�,Ep' ,permit�is fo�one hJndred dollars(E100)or teas.) - � . � � ���ttY �� - . � ' � NEA�ST . . ..7YPEOFCONNECTION - .�ry�yHpZpM.. : �. � I certify�haf in ihe�performance of the�work for which this caoss sT: � � E4 � D "� - y.: �� � c�y � �.i.- M.�.rp p.G.� � /,�,��I ,� },� ���. permit ia iasoed,I 3ball no�emplay any person in nny.manner -� .� : . � ... . ' . il. '. ' .M iGbihE- . P.C:NO�. � � ao os to become wb�ed.lo tbe Worke{s'Compensatbn lawa. � p„��R�. � ��-} . �i K�t S/�.�'�. � cn:iMc.Np. � � � .�me No.. �„3 � . . � �� � ��� ' � . I U , . �/ yy,.����� � , ,�� / �'��' ' TIIUMkPERM�TNO. � � � ���ROADPERMITNO.. Dafe / .2r Apptican✓�- F�=�-L1.�3,."-�-/ ,aooqess �,�i.� �R-''��it� . . . � ' � '.. - NOTIC �TO PPl CANT: If� OfiBf making fhis C9AifiCCie Of � CITV NO. �/ �.- ��.. ' 'APFIDAVIT WAIVER EASEMEM 'RECORD.iNSTR.WO. DATE i � . 0 , � Exemp�ion, you ahould become��svbject to'Ihe �Workers' � � � . � �,� �' ` � � � '- - ' V � Compensation provisiona of the Lobor tode,.wou.in�sT forthwith�� -' oescRianow� � . �otruc�.� r - - � � � � ' � HWY.ORST.WIPFNih1G. . � I d' . , -comply with auch�proaisions or.lhis permit-ahall kie deemed . � 'I � -� � � �H� � reVOked. ' �. . .... . ..� � � ' . ... ' BIOCK �:'TRACT ��. ..�j^JI� . �. . .� STATEENCROACHMENT � � � Z � I �� ���"tIGENSED CONTRACTORS-bECLARATiON �� � � , . � v�r+mit No. � � - � '. j . . ; sae oF im � :/ 3 ` Now°F«.Bi i�s i � I bereby dffirm thor#.4m licensed under provisiona of Chaprer � � � . - - i � 9(eommendng with�Sedion�7000).of�Division.3.of rhe Busi- � s iu�oiNcs � - �� ' � . -auac,�s � �� � � . I ���ness and Professions Code,and myiicense is in full forca and�. . �. _ . . .. . .. . . _ . . �:,... _. ��. ..�. . �� � .EfIECf. . .. . . ' . .,�� .. ... � CONTNAROR ' CONNFC�IONCHARGEFEE.. . . �I . �� UCBlISE NUII'Ib8! ' ��iC.CIO55 � � .; ADDFE55 " �.-0�' �' - - ' REIMBUR EMENT FEE�� - ., � � i � �' . . COI1f��CiOf � . �. �ptC � . . ' .. DISiRKf NQ. GpDUP MAP , PROCESSED 8Y � , . � � �� . CITY... . TEI.NO � � `. , _� ' . � � ❑�am exempt under Sec. -� of ihe�.A.Co. iicenise no. �.� .. �.a�ss . /� �•:� .-.,.� � � �•• � � � No. � pESCRIPTION OF WORK �.FEf� ' - Plumbing Code and/or 56c: � of the � �� - � wHa� -� . � ' " � ��- HOUSE SEWER�pPINECiING TQ , �ATE VqI.iDAT10N � . B.&P.Code for the fol�owin9 reason . .�T �. ��vUeuC SeweR. . .. � �� � .',�-y� � � � . �. GTIC iANK SEEVAGE Pli OR FINAt. � . PITSAND/ORDRAMFIEID ' � '� f .. ' . , . ... .DOte _ . �.nRWIVATE p SPOS O BVSCIING i0 ,�., - .. � 0Y '�' . � � '. ' . $.� G ry r�n � . .�� • G/ !� � $Iflf1O}U1! ..� �.. .�' � ' CONNECT ADDITIONAt BL�G.OR . . .. ' � :� . . . ,I WORKiOM0�15E5EWER ' ''- "�'�' ' � • • • • � - OWNER•BUIIDER DEClARA710N � ���� - ► �. # � (� � � OVERROW SEEPAGE VIT,OPAINFIEI� �'.••.n.f C„ - I hereby�affrm that I am ezempr from ihe Coniracror'a Licenae � �exrN.ressaooi,a+rwEu.N.nNNo�e e �v � � Law for rhe following reason�(Secrort 7031.5;Boisness ond Pro- � xhe,uevue oa aeanmoN Nouse � �� � � �� �2 7��� . ',� SEWER OR DI5705AL SY57EM � �, . . fessions Codej: . . . � ` : .- . .. .. .. ... �. . ra = _ � . .. . , a� , . -�-I,as owner of fhe property,or my employeas with wages as - � � �� � � ' - . � � their sole mmpensation,will do ihe work and the structuro � � � � .O��.2 'Jr•�� - is not intended or offered far aale(Section T044,Boeiness . �,� � � � ��'��� �� �' - -' " � � � ��. i . a FrofessionsCode). OWNER'S Permit S l .S�Q ,as owner of rhe property;am exclusively conrrac�ing with AU7Hl7RIZAT�ON ?GTAL FEE � ` ' ` licensed confracrors ro construct the.project{Section 7044� - ��{qyE�AT THI$DATE.A�OMRAC�'WITN iHE HEREIN NAMED 4CMTRAppR TO ' � � , BVSI/IBSS Of1d PfOfB9510R5 COfI@1. � � � CONNEC7 TNE A80Y£DESGRIBED E%ISTING DWEIUNG TO THE PUBLI�SEVIF,R.��- . � "'"- '. ' ' - � , � , � CONS?RUCTION IENDI�JG AGfNCY �� . . . ��..�� �� ��-� " . � � � �. I heroby affirm.tha�there ie o constructlon lending dgency , , SiGNED THIS �� �DAY OF � `�' I9,,,_ ► � �� ����' ' :- � ���'-�- ` ���i '� for the performance of tho work for�whkh �his�permit is cnvr+eaoa . , - � � . pWNERSAt}ENT '" -� issued(Sec.3097.Civ.C:). � . . . ; . . � �. . � . . . ..��- ' i. .._�... �-. ... .. i . . � � lender's Nama � � . . .� . .. .... �ooa¢ss � " _ . .. , . � . � ". . � tende�'s Address � .. � �. . . . . �_. . . . . , .� ... . , ._. . : __ . . ... , i . . i � 1 certify'thal l�have read ih7s applimtion ond atate that the � � � , , '� �- - .� � --�- ��� � �.�.� � ��� � �� .above informalian Is�mrrect.f agcee fo comply with.ull founty� - ' �� , � , � . . � � � . -� � �, ��ordinances and State laws regubting Plurti6ing and Sewers, '� � . ' � � ��,:.... _ ._.._... . .. ,� ._.: . . �. . � . �' and hereby authorize representatives.of ihis Couny!o enter .� � � � � � . � � . �,�� � -, . . _upon the abave-mentianed Property for inspeqtion pviposes. .. . ."� .� . . '. . ..._ �. �..._ ... .. :__�� . � � ' , �t��/�-�...�� ,f s/,�Y ° ; _ . , SlgnafureotPermiftee . � �D fe . - . - � � .� �� SEEREVfiRSEfOR�XPIANATORY�CANGUAGE ' , , " �, . . . --- --- -- -T _._ _ _ _ .__ ________.__. _ _ _, -- - - _ __ _ - _ .._.__ � �� ,����„�� - �� . -. � � :�... � x , , . , _. . .. ., INSPECTOR'S.NOTES OWNER-�UFLI3ER,DECLARtITIO�T ; ' ' „U�ISGECTOR'S6IGNATURE,.. . . •� � .� ., `. . . �� . • ' .. � . �...�.. . '. ! APPROVALS DATE r . . - I hereby 8ffitm that I am ezenpt Irom theContractor's ' � t�w House sewea �� , _,.,_ , � � ��� �,���� � „ - � � ` License Law for thr.fo'.lobring teason{Section'7�31.3, ;� . . .^",� ' ." . . .•.T'...' .. . Bruixesr and�.Professions CodsJ:AxY,.city os,,corsnty j� � oOniNctr�oortionwt � � � � wbicb re uir¢s o ernait to cnxs ruct,�, � eunoi�oa woeK - - _ .._ .. :_ _ 4 P P } -� SEmC rAnne,sEEv.�i(gi� � �. . . . .._.. d neo[isb,or re a r an strrscture fprtor rot ifs iuua ce, I '�AND/Ok D2AMFlE�o _. . .,, .__ . ., . . ..... � ako requeres e6e�appt��ne�or sucb errxi�t !o fiYe a�. : CessvOoi:❑ oevw¢u(]" � � --;\ � geed statem¢ni 'tbat ibe `u licensed prirsuaat to Cbe � . " . —. -.- ._---.." ..-1..., ....�'.. `.�: ' '. - . procvsiona of�ebe Cmitractor's�Lice�sa Law(Cbapter 9 ' `�atSttY,R�pAIR,SEWEROR ,t°:._ . '-�i� � „` - . . .- ..� . ... "` ��' (eanmenrieg�tuixh�Sectiex ZOOOJ of'15ivisipe 3 o,J"�be . � S�M`.AGE lM5PO5AL SYS7EM � : .. .. . ... . . �: � . . : � dSCONNECFPtUGAfaO„� " : usi ss nda ofe,in o. f e ' x pt ' ,qyNppN.�WSFs�w�R � ,,,A.. _.. . . ' .��, . ' . �. � ��:Cberefroma n �be ��isJor tbe�al[egedex mpd'ion;Any .. . �;: , , . a bas . . . aaaFiu�sErncuwcs,p F �.,violatdon.of5ectinn`/031.Sbyanyu,Qplicantforaparmit � s�ev,art�r{]�.c;�3.sado�s O-- - � subjects tbe applicaat to a civil penalty of eot more thon �_ 4 ,, l ,,� . ,. , five ar{(550�� , r` � "... _...... �'- r ,,.�� . �.. . . `�' � � . '. . ���as t o�ner o£the 'ert tsill do tlie�ork,"end `, r , , fl' ri Y fi�' f � , . , : � � . + - .,",�;,�, ','.�,��. "__�,.,,;, - , � �•-��.,;,, - �"�rfie sxrucRure is not intended ot'offered for sale: - ,__ ._..... �.. ..._., . �.;:.._.. ..� .. .._._� ... . . _�. �� :.(SQc� 7044.Susiwess ond Profesaio?es�Coder The:Con- �, ... �.- .� . ...._.. . ..� . ... _._.. . . . . '.-,.. p p terty wfco bssilds r�rn�ro�es tbereoa�and+uho dqas .... ..--- _ . _..,. _ . . .. ��, p h °o p v : 0 __. . _. ._.. �.. . � „ .. , ., such,auork,bimselJ,Pravided tbat a+�cb.iroprovements ' . _ . ....� ......�.. � . ,. '��. � � ..} �`� . . ,..,.are not inter,ded.or off¢red forsale, If,bowe{�er,.tbe � . �___... ._. _.. :. . � . � ...._ . . ._. . ..._..._ ...._. _ . ._..._ _.�:. .. , �.- :-� ,�bntldir.g.or irxprovernent is sold wrthia o„��.ye,P,ol . ' - ` ,._... . �.____ . ..__._. . .�..'._.. ..._ :.� .. .__, . , . ..-_._ ... ... , : �.�'` ��.-�� �.- .-:.rnmplu1tionr.the�ounsrbaelder�:vrill..bww'tbe��bnrden � �' ��` � - � � ,�, -,1', � '�� � . � ofQroving tbat be drd aot build or imQroae fo�'�tbe .._.. ,_.._. . . __.:. _.. _.._____ .. .. . _ . . . . . . . .. . . . _ _ . PurposeoJaade.l; _ ' ; �.. _ .. ___ .. . _ '� � I am exempt under Sec.� ti ;: E _ _ _ � ' � l i '�.y � -, 'i `�, B&P.G for this reason '- . .....:. , ti, _ � _. � . . . _ _,_ _._. . . ,, � i .. ' �� i ^ - ; , , ; �, __ _ . . _ _ � . , _ t , . � . Date __ . , , � ,. ` _.____ . , . . r I __.. _ , ._ pwner a . . ,: � , , � � � . . , , , .. . � �r. ¢ �' � , ( � ., .. „ INSPECTOR'S NOTES . �._... ....._.._ .��. . .:_ �.:�I, _...� ` �� .�.: ,.. .. , .��� . ,� � � � . . � . . .. . ._. _._ . . � � �� . . , � � � ,. . ... � ,y - . ___. ,.. _... _. . ..-,� , .:. ., . � . _. . _. , . � .. : , ' . . " r ,.�, �..:.� .. __ , . . � � �� , ,., ' . , . � '; . ,.. , , . . �� .. .: ' ' . , .. . � . . .. � . �� . . �i .. .. ._' '� � , .. , . � . . S. . ' : ' � �-. � �. . ,.. . � S' ' '. � � . .. ..-.. i• _��. . .� + .. ._._. .__._. . . .. ....... . ,�; ; S .. . _ . .... .. �:�,. ,..� � ., .,.,.. . . "' . f - , ... _.. ��. . . ' . . _ .. _.:.._ . .___ . . , ' , � � � � .. � , � ' � .._ _ ...� ...�.. . . � - . . _ . . � . . _ .. ' - -. i • . �. . j . ., . . �. . � . ., - i . . . , , . . � i i .r, � , . . .,. . . ...... . . ,. 6 . .. . . . . - . � . • �_. : - .. . .. , . . . ' . . .. . . � " .�' . . ', _ , .".