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HomeMy WebLinkAbout1804A (10) --+NORKERS'COMPENSATION DECLARATION ... :�.�:. ��:.� . .. ":-��.� - :.. ', .--�. �:.- ��..� .- . .- :: �..�.. �. . . . . I hereby dffvm thai I have o cerhf�cate of�consent to self ... _.. . �,,::. . _.. . .:. .. . _. . .... . . nsure,or o certif�cate of Workers'.Compensatio�Ins�ronce,or 6^E 2° � r -- � - �_��' � � � � � �'�i .�o cenif�ed copy tf�ereoi(Sec 3800,Lab�) - a'/C-e�e aev:: a., - � -- -�- - - �u po,;�y Na �omPa�Y APPCICATION: FOR PERMIT _ ,_o. __ . . . .. . » .�:_ ., �ryyy� p �r �.y y� � � _ . . . � �- -� ❑Certified copy�s hereby furnished �� � � �� � -� �` SC�YC� �.SLWaVE V�S���L �� e hfied 4opy�s f�led w�+h�Fe wumy b�ildmg inspection . � COUNTY OF LOS ANGElES� �-- BUICDING�AND SAPETY -� �- .� �� q'� / � _ __ _ . _ . . ,. : - --� depdr�ment �14� �'�r,fC''�C� . . . : .. . .. . . . . DareM,��`Applicant - � ___ _. ��� '� FOR APPLICANT TO FILL 1N �y� CONNECTION DATA�� � ' CERTIfICAiE OF EX�i41PTION FROM VJORKERS' � ____ auuoiN� � � - �� - � . �`COrv(PEN5.45'I"ON-1NSUkANCE: ��_ . aooeEss�� . �.�f� �!s''� -srr.noni - . ��.�� certr+ . ,._(This section need not be completed rf the work involved by.ihe � ��iirY . ..��..f� - ��.� � � � - � _MyN'p�E pppEaEucE .:.._�g/ UPPER� .' permu is.for one hundred dallors.($100)or lest) - . - - _ . - � � p�� - I cerirfy�ihat in the-performonce-of ihe wQrk fo�which ths - �E�555T, �� ��� �� �-�-� �-rvveovcONNeCno . . . t�NGinFRO/n �.��ermi�is-�issued,I sholl not employ any per@on in any manner ��-� � .. Y� -NRe" -v.t. - nn�To.v.t.. ��so as to become sub�ect to the Workers'Com ensaiion Laws. -�.` _ . -v_c r+o. G3�i/�3 � P OWNER � . � CO:IMP.NO. - JOB NO. /7 �� - ��� � TIiUNK PERMIT NO _,_. �ROAO PERMiT NO. � - --� �-� �bate ��� ' APPlicant �..� - _' � --� aooxess fl , G�° -��'d' � . . .. . . .. -rIOTICE TO APPLICANT�.If, after�maki�g }fti5 Certifl[ale Of ~ ��iy � iEL.�NO. - � � - AFFiOAVR- WAIYER�EASEMENT -RECORD.INSTR'NO. UATE . �--Exemption, you shoold become subjeci� �o �he Workers' . iECA��. -.- . . . . � Compensanon prov s�ons of the Labor code,you must forthw th- oescarariau �-� to*No,.... � L' Nwv.oe sr.wioeNw� . c6mply with such.provisons or ihis permit sFall be deemed � � +� / - � - - --- - � - '��r�VOItCCI, - &OCK- TRpCi'�-- -� /�L'� STATE ENCROACHMENT -- � -'�-��� -- �- -� - ��LfCENSED CONTf£At70R5 DECIRRATION - '�` �� na oF eiocs � - --� �aMir No-�- ���-- - ���_--� - �- -� �- �" � SIZE OF LOi N6W ON lOT - -� I hereby off rm tTiat"1:6m I censed��under provisions oi Ch6prer �-�� �sEOF� � � � - � - -- � � "'9(commencing wilh$ection 7000)of�vision 3 of ihe Busi �. sw[ow�s - ��f� � cHna�es- - � - �� � � <�ness and Professions�Code,andmy I�cense�ii,n full force and � �'' - -� � - - � � � efleCt � �. ... . . '/� � . CONTRAROR -J�[.;�r � .R� d.�.'� . CONNECTIqJCNARGEfEE. . . .. . . .. �..�LiCense NVm r�liC.Class �"_�` �- er.- �^�' .. y�., �.. -REIMBURSEMENT FEE . . } .y" `� �_.J. . .:. AD�RES$ �. � G.4=� C.A�✓C !@"= � . . .. O. �COnffbCiOr� �< 3' �Date Z `�7"4 T ' . Op ... ..... DISTRICT NO. GROUP... Mqp' . ' -ES$E�BY ' � . , . ., . , . CITV � ' --TEL NO �f �.4��- BK PG V -'C 1 am exempr under5ec. ��� of the LA.Co. -uCeHSE No '3-� � cLn3s�•— � � p � o � �� DESCRIPTI6N Of WORK` �E ' - �- _ . . F - PlumbingCodeand/or5ea � - 'ofthe - FiNai V/�LIDATI�N r.Vu-"� : . �-- "' ' - HOUSE SEWFR CONNECTING TO��� -- OAiE �j � --�� ' PUBSICSEWER' - . ���� ,g B 8 P.Code for tFB follow ng�`reoson � SEprlc rANK.5EEPqGE Plt oR�� � � � `� J � �z vR5AN0/OR.DRAINFIELO - - FiNAI . - � � D4lB � ' PR1VA DRPOSP.SYSTENGTO-.. . . . .eV. . . II : . ,., _,_ . 3 �c.�fl $Kjtlatu�2 � ^ONNECT ADD�TIONACBIDG Olt , '" � � - � - � �� �� WORK i0 HOUSE SEWER � � �� OWNER-BUILDERbECIARATION " ` ► � - � - i;• o e.e '� C . OVERFLOW SEEP.4GE P�T ORAINFIE[� � � - -I hereby aff rm that I am exempt from ihe Contractor's license ' ex*N cEssvoa,oarwEn.MaNNae ' � � � �.Law for the fo�lowing�reason(Secton 7031:5;Buisness ond Pro- - uTea,aeania oR�aaanrooN eOuse ` --�- ��� �a`a�s-�7.J�U.� . - - `�fessio�s Code) �... . �. .�... _. _._. sewea oa oisc�snt svsr[M � � "� . .. . .. . .. . . . . . 7 ic -c�i > C I,as owner of ihe property,or my employees with woges as � - � "��,�,�-��[�'�'� their sole compensation;-will do fhe�work pnd-lhe stcuct�re --- - � - �� ---� . . is not intended or-offered for-wle(Section 7044,Business � � :- .� and Piofess�ons Code). OWNE.R'S Permit E �r � _ . _ ----- -� �i i,as owner of the ty,am ezclusively contractinq with � AUTHORIZATION .TOTAL FEE � � proper . _.. Iicensed contrac�ors�o conshuct the project($eCtion 70A4, - . I HAVE Pi TM�S OATE A CONTRAtTVJITH iH�NER[!N NPMED-CO..RACTdR TO- BUSInE55 On(I PIDFBSSi0�15 L0C3e�. CONNER THE ABtJVE DESCRf9E��EXiST1NG�DWELIING TO iHE GUBLIC-SEW£R � - �� CONSTRUC710M1!`LEN6fNGAGENCY ' '� ' " �` - - � � -�� � ► - �t he�eby affirm fhat there is a constr�[tion.lending ogency SIGNEDTHIS DAYOF 19�� - ��for the performanqe of the work for'which this permit s Ow�ER oa , . _ .. ... . .... OWNERS AGENT�... . ... .issued.(Sec.3Q97,Civ.-C.). . . . . - .. . . .... .. ... . ADDRE55 -�Lender's��Name ��..:� . ;.., .. •:.i� . :-. _ :._.. . ._. . . _ . - . ,.,.:. ,,. � .,. _ , .:.. . . . -��-Lender`s�Addiess - �:��.. � .�' -:� � � " , ,:: .. .� ' .. � . . _._.:, ._.° . .._..... ._...,.. ..___ . ,. .., _ . . . _ . �� I cer(ify iFiat have�read this appli :.:on ond state thpt the. ... . � .. .. .. .. . . ...... .. .. ... ..... . -'above inPor etion�is correct.I agr ro comply with alYCounty�� �- �� �� - � �� -�- �"- ���--- �� - � - � � - - -- ..�ord nonEes �d Sate laws�re oting Plumbing and Sewecs,. .. �. . . .. . '-. ::: - -_ . _.__.. . . ... . ,._ . . . . .. . . . . . . . .. . . ._. _. . . . .. . .. . . . . . ''and her ,y ulh ize'repr enrotives of iFiis-Coun�y�to enter �� � - - � - � -- ��- - - � � ---� ��- - - - � � . -'-upon ih `a v - entio d propert for.irispecti 'piirpo4es... .. ... ..... .... .'- � ..'.... .. . . . . . - .. . . � � . ._., . . . .. . _ .. . . . _. . .. .. ....��... . . . . � .. . . . . � -- ' .. . . _._ _ _. . ..,. _ �.,� ...._.-_.. ___. -_' ___ . �5ig Ture oi Permittee ��- . Dafe` - � - - '--� � SkE REb�E�Ok�EkPYS�pATORV L�iiF3UAF'iE���� �,��� _ . . -'�� � _ _ , .. . : �K .; �a���:u��s�€���s , , _ � . �b�'\�'�YY�€,1�3��'.Ya s��CI 4�;�3`IL�\ . > � ... � , ----- 1,. . . . .,..,. �.n __ . , . . , : �� . . , . ,� , .. i ..��.- �i'��'G34�€� a. .�- as ecrcRss�rw+..ae . — __ --- te�reby�t�i n tta* .�-r n c«mpt`:`ranz he Cn^¢a to s�� � - q n�w++ �se sta�� _ �� l ... ..- ,. .,.. -..:. ,_. -. . .:.:13a enrss ard Pr��s�s or.�i�,;�rdc�1:,j�.r 1(ar e�lnrds',a.�h�: , . .:: ,.,-. . : - . ��C�Ny:CT AGi��ioN9 .;:Y . .-�-. , . . .„,_ - -- � -rrguer a oer+�.t! cutis4rlut e te,`unpro e�er+to asn'or.:. .. �auF��Necev+ogK.. _ . .*� -�sr:- � . :� .: .._ , ,. . t . fft:=i1ts . .� �_ _. �. '- .— - _ — rc�.rxr,w y afie[cittm prtqr s [anc a oY.nunes�xe.- �cP�iCiA K a..- � �.� _- ,_ ; ... . , ..-_.... ."—'�—"" _..� .� ._ L SSi J Atd�/D �Ra+r.�:e,�-- ... . - ... �."'ryy.rwzf�o�sucF�rnii tofi,z a 3�ne� tatemenetn dee is eiss.._?�,..� �avW[E.:G_.��. - —_ - -. __- 1se sed yutsu�xt in �fe�rn>s ir��n hc L'err u,.t�:'s. . ^, - - .---_ , ..-� . .. �-1- f , _ _ T nla2� r�s4a�e�c� Y.�.� .=.. . ��- � - ._ ' �� : -13c za n 4 nf t e�iur sze;anu 1 cofelss nt C51c h�nf7F)���o .: �SEWA.. C�5^OSA.SYST Ff +; . -� ._< '� . ' - - - - _ � 1r pt tFerefr�m and the bae s jar e u(!bed�x np(osi .c�sen eNNe* ��.u, u . .. , : ., � '.�.: t vse�a oi'�o�' zc`�e n 7b b !e r a �c rt Yci n c r�u � ��Asan�s.w� - -- � :`. , -- ... .- . -- -- -- _ :�� , S o 3 1 �Y l ` . �"A�KF SfTK-iAN%5�" .� ; '.-, . . SUU�&Cl I�it [[�'i�S F� !l d . _ �����nrf3 sussPoo�s] ._-� ._f:_ ._... _ . . .:_ , �. . ,_ __.t.� ._ __ — . ..nt�ndrsd drsCiars($�QIJ - .. . tk I� } a � -..ceci7 pena'1}ojno n� � ran five- - _��,±:;, ;- . - ' ..�-.� . _ . .. ., ...,_ .. �.;.-, , �.,. _ .r; . ` .� . �.T,�as-Khe osnar u£ihe.Hruperts w,�li do the�aor�.;av:e.. , . _. ' _. ; .�'._ _ _ :. . �._ ,_ _ . m.._r: .� :._- :`, ._ . . _...� _ :.:. _'_ _ .. .._ . ._._. _:_:.t;�e :ictur:-is not ir::eesGed or�offerea o s.i:..-. . . , . , -: ., ; .: ..: _ � ._ ,, .. _. .�_. .... L_. .. ... ... . .. . .. ... . . _. 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