HomeMy WebLinkAbout1696A (10) - _ __ _.�.. --. _ -`°r
� � WORKERS'COMPENSATION DECtARATION �
-I hereby affirm thof I have a cartifitab of consenl to self �
insure,or a canifim�e of Workers'Compenwtion Insuronc or . �bn6eao
°�°�'���°��`�«.�� �., "�,"`�°,B'> APPLICATION FOR PERMIT
PoGcY �s
❑Cerlified copy is herehy furnished. � SEWER • SEWAGE DISPOSAL
❑Ceriified cop is filed wi�h the county buildi g' spection COUNTY OF l05 ANGElES BUILDING AND SAFETY �
depo enr
Dore�APPi�co��— FOR APPLICA TO FILL IN _ CONNECTION DATA
CE IFICAiE OF EXEMPTION FROM WORKERS' euiio�rac
� COMPENSAiION INSURANCf � �ooffss ST�Ti°N - °E°TH
(This sac�ion need noi be completed if the wo•k involved 6y the ��E���� urr�R
permi�is fo�one hu�dred dollan(5100)or leu.) ���A��TY � R
NEAREST (' TYPE pF�ONNKiIpN �ryGTH fqpM
I terrify tha� i� �he pe�formonce of�he work fw which this �ROSSST. Y. CURB P.l. M.L.TOV.L. �
permil is issved,I sholl not employ ony penon in any manner .
so os to become sub'ect to ihe Workeri Com �salion Laws. v.c.rJo.
� , � OWNER CO.IMV.NO. 108 NO.
� M'�'�� MUNK VERMIT NO. pOAD PERMIT NO.
Date Applicant nooxess
' NOTICE TO APPLICANT: If, after mokin 1f115 Cerfificole Of ' � , . AFf10AVli WAIVfR EASEMENT RECORD.IN$iR.NO. OP.IE
9 CITY TEI.NO.
E.emption, you should become subjeU to the Workers' «Ai "
' Compansation provisions of the lobor coda,you mus�iorihwith pESCpiy}�pJ �lOTNO. HWY.ORST.WIpENING
comply with such provisions or fhis permit sholl be deemed
lBVOlted. � BLOCK TRACT STA7E ENCROACHMEM
- LICENSED CONTRACTORS DKLARATION NO.OF&DGS. PERMIT NO.
I hero6y affi�m lhat 1 am licenud under proviitons of Chapfer 5¢eOrior rqwOr�l07
9(commeacing wiYh Section 7000)of Division 3 of the Busi- BunoirvGs ,CM�kGES
nass ond Profeasions Code,and my licenae is in fvll forte a�d
QHECI. CONLRACfOR ,' CONNEC11pN CHARGE FEE r
License Number Lic Closs � J p(�MBl1R5EN1ENT FEE �
AppFE55
ConifOCtO �pIR OISTRI[T NO. GROUv /�qp PROCESSEO BY V
� G El.NO BK �G ZO
s�A ��� �,- (� �3 �—t—
❑I am exempt underSec. af ihe L.A.Ca uceNs�r.a. cu55 �
PlumbingCodeand/orSec. ofthe �o oe RIPTIONOF �[e ��N�i
IqU5E5fWER�pNNFCfiNGTp DAfE VALIDATION �
PVBIIC SE WfR
B.8 P.Code for the following roason gvric uNe,s�vnc�t v�t oa �� _
� PITS RND/ON ORAINfIELD FINAI
��e r MOUSE SfWER CONNfCTING TO ' BY
1 vpNpTE DI Y I M
si9�ewre ca+Necr�ownown��oc.oa z 1 6 9.6 A
� OWNER-BUIIDER DECLARATION � woRK i0 Nouse sew[x ,
OVERFLOW SEEP�OE PIT,O4AINFIElO
I heraby affirm thot I om axempt from the Cont�etlor's License EXiN,CE55POOt,ORYWEIt MANHOIf h a � � � � O
Low for the following reason(Secton 7031.5,BuiSnBSS and P!O- AtiER,RFPAIR 6R AlANDON HOUY -
fessior,s Code): .- s�wER oR o�svosu srsnM I 4 •5 6 5 0
� ❑I,as owner of the proparty,or my employees with wages as • r °vr,,�Jr O�
their sole compensation,will do the work ond�he structure �
is not intended or offerad for sale(Section 70M,Business 0 9.1 6�8 7
and Professions CodeJ. -- OWNER'S Permit S � �
❑I,as owner of ihe prope�ty,am exclusively conrrouing wi�h AUTHORIZATION TOTAL FEE Q
licensed contractors b construct ihe projed($eUion JO41, I HqVE AT THIS DAIE A CONiRACT WITH TME NEREIN NnMED CON'MC70R IO '
Business and Professions Code). CONwECT TNE ABOVE DESCRBED E%�STiNG DWEu�NG TO TNE Pu&�C SEwER.
CONSTRUCTION LENOWG AGENCY ' � �
. I hera6y affirm tho� there is a conslruction lending agancy S�GNEDTH�S DAYOF 19_
1or the performance of tha work fo� which fhis permit is o'��4ce .
issued(Sec.3097,Civ,C.J. �'/�'�RSAGENT
AODRES$
lender's Name
Lendar's Address �
I certify ihat I have read this opplicot� n ond slate Ihat�he " �
above information is corretl.I agree c ply with oll CouMy � �
ordinances and State laws reg�iali g P mbing and Sewers, , �
and hareby aulhorize repr ntat' as fhis County fo enb� � . �
opoa� ve-me ned op Iy r inspection purposes. /'
S g ture o rmi Dale �` � tE[RFVERSEFORE%PLANATORYLANGUAGE
J -- -- - :J._..- ,,�
: ' ��CTOR's�'tOT� OV4NER-BUII.DER DECLARAT'ION
APPROVAlS o^T� �Tce'S�'+�� I hereby aff'um that I am exempt from tke Contractor's
� . Liceme Law for the following reaeon(Sactiax�7031.5.
NE`NHOUSESEWEF . � ' . .. , . . . BYSf/Ilts �r�.u:o.: c�l:a.y rir�.o.ro,.,.:y
mrrt�caaoortiorini ._ . . ._ . . rubieb.requlnr a pennit Jo roasatr�et,eltor� inrproue.
t
941�DING OR WORK ' ' ' ' df!lJOltflj,or nyair any s{rwtlarv,}rior to ita srraa�ce,
. SEVfiCTANK,SEFP,PIT(S) " /�I�rWa �IC�1 f � �f�C
AND/OR DR41NfIELD -"- '" ' ' -' - - -" � � t Of SYCL ZO p
� sign�d smt�rn�wt 2bat 6e ir licrwrad pursuawt to tbe
� cEssvoo�❑ _ oavwEu O - - - � - . proutsiowr oj tba Coweraetor's Lknuc Law(Cbaywr 9
� K7ER.REPAIR.SEWE4 OR . � �C'0�11MYIM1�1u�ilJ.SiCiIOM 70001�+I A�K 3 oj tba
s�wnc�oisaosni svsr�
� qKONNERPIUCAND . . BWipaff ai�Pf'O,IfliOwa COdij Df/(16�11¢is B%HMp1
, - aerwoora ero�s[v.eu � tb�rafrom awd tbc basirJor tba allegrd arearpt:ow.Awy
a�«mi scvric rnNcs❑ uiolutior n/Sa�th�7037.5 by ary aypficswtJarap�rvnit
s�ev,vrcts�❑ assroas O - srbja�r sLe applieawt to a civil peiwlty ajnot more N�
. . . � five brsdrrd dollors(fS001.:
; , �� - - ❑I,ac the owmer ot the propeety will do the work,and,
� . _ the etructom ic not iatended or o(fered for sale.
. ' � . (Sta 7044.Bwiwau owd Profiuioa:Code:T6�CoR-
i+nceor's Lfnwee lau+doa:ro:appty ro ow ounwr oj
� - - . property wba brildr or bnproues ibareox,ard wbo does
'� . . . . sreb worle EiwuolJ peovid.d tbat sreb s,nprovr,nawis
. � ert twt iwte»dad or offered jor.ule.IJ,bov�rwr, tde
. .. -. - � brildir{q or unprowmewt ic sold witbrx oee Year oj
- , coaipktio�, tb� owMerbri/der wiU Gaua tbe brrde�
�' � � - . - ol P��a�biu be did,we awrkt o.:w'pn�cY fu.raa
. �- - - .Pus�w�of+ak.1 � � .
- , I am exempt uader Sec: ,
- B&P:C.for this reasoa
Date
Owaer
INSAEC70R'S NOTES . - � .� .
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