Loading...
HomeMy WebLinkAbout1305A (7) y- — _ _ _. _-- - ----- ---- - -- ----- ---^_.. ._. . _ ___—_- - ---_._.- -� -— -�.�. . � WORKERS'COMPENSATION DECIARATION i hereby affirm thm I hcve a cer�ifica�e of conaen� lo elf In� in�ure,or o eer�iiieore of Wo�kers:C mpenso�ion Insur ,or 76A6d4D �� a tertified copy thereof(Sec.3800,1�.� , �E��RE�.,,a3: APPLICATION FOR PERMIT " � aorcy,r�q�.�. ❑Certified copy is hareby iurnished. � SEWER - SEWAGE DISPOSAL � ❑Certified copy is filed wiih the counry b�ilding inapection COUNTY OF LOS ANGELES BUILDING AND SAFETY deporl ent. Dore.,�`���Wvi�com FOR APPLICANT TO FILL IN CONNECTION DATA CERT ICATE OF EXEMPf10N ROM N ORKERS' pusqr� � COM�ENSATION INSVRANC� �tm¢t55 5*�iwN. o[v7H (This aection need no�be wmpieied if�he work involved by�he i«µ�Ty ���� M.,r�+�o�E Rttcer�[ �R permil is for one hundred doilan(5100)or lass.) ��5� ir�[OiCONFECiqra �EbK;TNfROM . I certify�hat in�the performance of the wo�k for which �his teoss si. r. Cuc6 P.t. M�.TO v.t. permit is issued,I shall no�employ any penon in any monner p�� so ds lo become subjetl 10 fhe Workeri Compenmlion Laws. p�r.�Ea S y Co.uxv.r�o. �pe No � . . /AAIt TRUNR PEYAYT ND. (IWD PERMIT NO. Date Applicom �OO�u NOTICE TO APPIICANT: If, atror mokinp �his Certifica�e of ��T� TEi r+o .uFio�wr WAMR EASEMEN7 RKORD iN57R.N0. WTE Exemption, you should become subjecr �o �he Workeri IEGAI Compensation provisions of the Labor cada,you must forthwith pfSCmvTpN l0T NO. HWY.OY ST.WIDENING comply w7th suth p.ovisions or this permir sboll be deemed ' revoked. � eiocK TFAGi STATf ENCROACFIN�ENT ' UCENSED CONTRACTORS DECIARATION "�.a&�s ��T�� suE a ior r�ow or.�ior 1 hereby affirm that I om licensed under provisions of Chap�er �a 9(commencing with Sectio�7000)o(Division 9 of the Bubi- BU�LD�NGS / au�s nau ond Profnasio�s Code,ond my liceme is in full force and -/ . effecf. .f/ c-� Cp�diNACTOa �!/ CONNFCTION CM�RGF RE LicenseNumberf�°�Jp4lic,Class C" Z � ,�F� REIMW45EMENTffE 0. COnhOt�O��"'0� � UISTRICi NO. G40VP MAi V40CFSSED BY O aTr u ❑1 am exampt u der Sec. o(�he L.A.Co. ucer+st no � cuss�- 2 �d {�'� � � ���`� O PlumbingCodeandio�Sec. of�he "p KR���a�K �E FINAt V wvu sewea ca�+necriroc ro o�rc p 3 8� VAUDATION �u R1lLK SEwFR �8.B P.Code for ihe fol�owieg reoaon 1 ANK, loAGF PIT pq O F�Nµ � Z nrts nw�oa oa�uvrmo �ale �WtlSE SEyy[R CONNECTINCr f0 �� 6Y 2. SignoWro ' [a+N[ct Aooma�uu UOG OQ OWNER-BUILDER DECLARAT�ON WqIK T�Iql�SE uW[p ► �SOp C��.S��� Rriow i R,ORAINflFI J �here6y affirm Iha�I am aaemp�from the Conkotlor's Licenae � ex*rJ,cessv0a,ortrw[u nur+riat + Law for�he follawing reason(SeClon 7031.5,BUISnlS3 Ond P�O• PlTfR.REPAI40R ABA�DpJ IqUSf �'�'1 5� ���f (�, fessions Code1: . s��atR en o�svo6'u svsn'^ J y _ ❑I,aa ownar of iP e properly,or my emplayaes wi�h wages as �.Q� � ; their sole com nw�ion,will do�he work ond the anvcturo ia not in�ended or offered for wle(Sec�ion 70�d,Business � . ' � � ' and Professiom Code). OWNER'S Pe�mil f ►� G� , , . ❑I,as owner of the properry,am eetlusi�ely eontrodtng with AUTHORIZATION TOTAL FEE �1 3 Q 5 A litansed conhaclors lo canstrucl Ihe projett(Section 7M4, i HAVE Ai TXIS DAIE A CONTQA�i WITM THE MR[W NAMtp COMlACTOR TO ' - ' � • � � ' . N �'�'��' BUSineu ond ProfeuiDns COdlJ. CONNECT TME ABOVE OESCf1EED EYiSTING DWEIIING 70 TF4 PUELIC SENLG. � B• • • •7�� . � CONSTRUCTION LENDING AGENCY � � � � � ���. �5 G 5�p I hereby oHitm Ihat Ihere is a conslruction lending ogency ��EDiH15 DAYOF 19_ , For the performance of �he work for which this permit is ��qS�NT ► � ;•}•�•565�p= issued(Sec.3097.Civ.C.). . �' Lender e Nome ��� 0 1.3 0-8 4 Lender's Addreu I certify fhol I have read this opplicotion ond�tole 1ho�the obove informotion is cw�xt.I agree to comply with all County a.di�ances ond Sfere lows regulating'l�l�mbinp and Sewers, ond hereby aolhorize repmenlativm di this Counly lo eNer upon fhe ob�e-ma f'bne Oper�y f /mspecfion purpos / � ��L'�'Qe�z/ ��/� � aeure of Per�ee Dole � S!!REYEIKE FOR E7cRANATOM LANGUAGE � .. ' , . ' ' irasrecrn^�s r.ores � 01�'NI.R-BUII.DI;R DI:CLARAI'lON ' AFr�COVCrL$ o'e� � o�"ioo'sv:r:ranv� , _ _. �. ' � � .... I licrehy affirm Ihat I am e�cmpt frum the Contractur's' �I • n�ci.tcu•[sen�e � � . ... .. . ' � . Liccnsr L:rn fur �hc follnwin�rrason(S��rfiun 703I.5, . . ' . . . JTuurress nnd!'rajc�sians Code):An�ci�y�or eo�u�ry phieG' C�hl�[ AC ,S�CV .— • •.. . �.. ._ . . . . . ' � a euito a o wo�. ._ . (� . . _ .-: .. . . � . . . . ^�r.Usre r i i/' � (J � — rrp�irm 51rt¢lure,prirrinttlsr\srmncc,lafsnraquitt5t,11rc AHoio.w.4..iu,- � �- ��/�� �`-' /'j .L�-..-._.-. .. ..-- .-...�_ _._.. ._�- _ ... ... .. - app�cnnf fnr vrcli prrnri!!o fi7e a sigurd s(olrmeulllrat hc is - . . -�-/�----�'�r V . ' licrrrsed puraumi! In fhr procisions of thr CuntrnclUr's CE55i`?Ol Q_. �2YJ/Et:Q"_ _ . .. . � � .� - - - - . .- -- . l.irrase Lnx�(Chnp(er`J(contnieneing x�il/i Setlion 7U00}af o:t[F.'�c�>ia�[r,[ce; . - .. .. . . . . . . � � Di�i<iart3rf1hrliusi�rrssmtAPr�J�.csiai+sCodejor1ka71reis� sc::AGE[^.?oie�,sr'.rr��__':". _ __. ___. _ _. ___— . � . exent�(lhrrefrum n+rd!Gr ha.cis f>r die nllrged exemptinn. c'S[eva[:r r.uc F��' . . ... . . �. �� Ari violaliaa n Scclinn 70JL5 G nn n Gcarr( ar a crmil nanNM ��.<<t ....._ ._ :.�. _.... .. . .. . ._ _ . S � l' Y .f P' e.:cKr i [ �rc� s p I . , . . . . '. ..suGjrcte lhe,aPPficmat to n eiril pennlq•.�f nnt mnre tlwn fire e:[r. ...- C] v�. ...s❑ + : . _.'_ ' ._:. .__ _.- . - . . _ . .__' lumdred dollars(S.i001.: � .. . � � � � ❑1,as thc o�rncr of lhc pruperh���ill du lhc»ar6.ancl j -- __._..� '� ' -. ..� _.� --._ � � . _. _._....._ . ... _._. ._ _ . . _ . . . - thc structurc ls not inlcnArd ur i�ffcred for sa1c. � . , f ' � .... ' . __. (Src:70J{,1lusirteamrdProjts,sini+rCoJr:7'lirCnnfraclnr'x• ---� � " � - � -�-'- .� . . � . . . -. . .- � - �-� � Licrnsc Lnx��dn�e ren[app(v m arr oi��ni�r nf propern�w�G�i i . _ , � � . .._ . .. .. . .. .. . .. . _� briilds or in+prnrrs lhcrcw�.midµ•ha dues such k�ork kbucrlj. _'__. ..._ ..... ___. . __. . _.__ _ . _ . . ' , , , . . . . . ' pro�'iJrd dmf sud�intprorenre+t[s are not irrtenArd or nffrred �' ___ _ .. . . . __ ._ .. � �. . . fur snlr.!I,hon•ever,the 1 r�ilrlinF or iu�pruremerr(ie snlA _ . --_---- ------ .. x�i7hinone}•rarafcnmple�iou;Nieox�ner-b+�ildrri��illLm�eUre . . - . � . � . . - -- � '� . , hurdrn of proring d�a1 fie did iiol huild ar rniprnrr fv.r lhr ' ._._ '_. . . .. — ._____.._ . _ . . - ' . . purpnsr ofsnle.). . . . - . �- . . i .. . .. _ '. ' _. . __ _ ._... '.. .. - ._ � _ � . , -.' . , .. � . � _ . _ ' � _ - I am exempt undcr Scc. , � - ! ----- - I3&I'.C. for this reason F ,j _'�: ti , ' , . ' . -- - - - i . . , . ......- --_,. _ _. ._. , , Datc , , • , - _ _ . - - . _ . . _.._ .. . _ .. _ _. _ Owncr _ , INSPECTO.^.'S HOTES. � ` •�'� : : ;. '_. � � - . . ' . ,. . . .. . � �R� " , .. _ _ � ' /� S_ —��'u`rs�v ..���iG ; , - . .� . /$� `f - - . . - - � .�'�-�i�'s L oG.9�otiJ _ , ;.�nP,e,���� �y�� _� - � _ . . .. . , , . EAIG. bG -7" � - G� oG,s yu.,,,� . . p . - -- - - -- . _-... . . �, , . _ ___. _ _ . - � _ � . ..