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HomeMy WebLinkAbout0924A ; WORKtiRS'COMPENSATION DECLA '� I � . � . � Fd ,�R� 'eby affirm that 1 have a certificate o� {(1'' - - � �I ... .. :� ...-�, � �'s For a certificate of Workars'Compensat 76A6W2o -� - . : . . .. . .. . ified copy thereof(Sec.3800,Lab.CJ BUIL ceeoeiaev,�� � � � - - s. � "��' APPL[CATtON-F`OF�FPERMI7`- _�., _ __. �, ry y No. Company cirv SEWER- SEWAGE D15POSAL �� � �� '�� e � . . . . _ e k;ertiCied copy is nereby furnished. sizE COUNTY OF LOS ANGELES'' -'` `$UILDING ANDSAFETI( Q Certified copy is filed with the county bu � 9e . Tqqc - . . auxe�civa..= anave ua. _. eaoc�sscasr _ 9 pepartm nt. FOR APFLICANT-TO FILL IN -. -_ ' _... _ _ � , , . . . .. . :..�. : gK.::..... PG.-�., . � GUILDING I�//�..[`' .. . ... . • � ... �le FI./ f Applicant OWNf ADDRE55 J.[4'�✓e , r ��Il� v... �- .,..:_, ...:_. . (� .:� _ ... _. ., .. ... . °J I. �}G � nooi � �' ` ONNECTION OATA I �y FERTIFICATE OF EXEM ION ROM' �ocn�rrv- �CQ.:-)' `7 - �'t" .����' . . _ . .. . _ _ . J � COMPENSATIO INSU ANCi NEAREST ' �` '" � • '" ' STAFION�-' -"DE'4ff `^ � III . E P aTv r�osssr. 2EG�C -G��Zt- !,� _ } c ..._.. -- . �n f section need not be com leted if 1he ARc� } - ��u,��E.��„�e- ,-- -- uv►ea O �e ecmit is for one Lundred dollazs i ENGI OWNER '� � `'�' � � •.' - �� D V C, • %'C�X,JGY'�L C' -�.�+:.� . 1� TYPE OF CONNEGTIO . LENaTN PROM-� - - � �.: .- ADDI MI.IL . / � .w� f J/����� .. Y. . .,..._..- CURB P.L. M.l.TOP.4. � �ify that in the performance of the wnri ��RESS� ; !Q - G�.��y�.t�r /�(:.-, . � -�� n' �t is issued,E shatl not em lo coN'. ; .. - . . . : � ' . . . . . '-.-�� � - No- V Y any persoi ....�G ..,... CA..�rv rwd. , .. . :. ...: �craw:. . � .. :.: U �f !.to become subject to the Workers'Cum: urr�� i. -��,LL� ' rE�:no. Ifj/� r �� � : ._ ' W @S . � ADD LEGA4 -- ...-..: -:�_:_- . TRUIVNPERMtTfiO. ROAGPENMITNO. a, ; 'IS ! �ESGwIIfqM � 4OTN0. he • APplicant CIT1 . FFIDAV{T W�fVfN EASEYENT NEGORO WSTR.NQ. ��TG — � � . . COFk BLACK -..TRACT .-. .' ' /�� .. .... a f . .. ' � Y. ,,.... _ _ �`.E TO APPLICANT:If,after makin thi� NAM�i ' �� -� no aKe�ocs ��- - - o�l . , B SRE OF LOT - NOW ONtOT" .... HWY.OR ST.WIDlNifiG . . �tion, you should 6ecome subject to ��q� �� �� - � � - � . � . .... ...... ...., .:. ��_ he ;nsation provisions of the LaAor Code,y A�� BUILDlNGS . - :.-.: ._. STATEENCACfCkiNE6[C'� .. . .." .. . . _ � 'omplY with such provisions or tRis p SQ. . . . � J . .. "'� .' . .... ... .. P�..rt No. � d revoked. SRE ^" - �.' tNDusitttAL�� . - cowrr+wciow' (.' f��"tG}'C.L��� T' . �'L.0 �� : . WASTE ArPROVAL. ... -. ... .... . , rnj .. •.� ,-_ � i ❑E$ ADDRE55 - .• � .� .._ --.-..._ ... .. G1tAfIW9 . . . . . ...�... , .. . . � .LICENSEDCONTRACTORSDECLARP �R„ .; ,�,��„�- , � �t¢�no.�/j� ��'��G'�L',��� �QN�GnaKCNnAceFEe ' ..� . - -�- .. - - � /l. . ... ._ ,.. _ . j iy affirm that I am licensed under provisi� 510ENSE NO. � �Y� Ugg G���-� - _-- �y������ � � 6 i ImenCing wtth SeCtion 7000�of Dive5lon No. DESCfilPtlONOF WORK re¢. � � pppapyp� oATe irh� T �•ssrc.NwTuieE (g� E . td Professions.Code,and my license is in u5E , qpySE SEWERCOMNECTIN�TO" "'" '' ' ' ' ' ' � �. EXI� � pVeLICSEWER' ' ' ' ' � , /// qpp SEYTICTAMKSEEPAGEVtTQA �WH�USELEWiA Y � f Number� D Lic.Class�� (p ' P�TS�AND/D(iDRA1NFIELD- � . � COHHECTAOORION/1�� , � • � - ` HOUSESEWERCQN/iBGTWaTO -�'�"-- -" �."" ' 9ULLD4NGORWORK "`- ' � �Of �v PRIVATEOISPOSALSYSTEM L .' .. .. . ..� � Date� 8 V t CONNECT NOD{TIONAI BLDG.OR . SEP7iGTAAIK SEEP.PfF{i/ . . --.-..- _,- -...(/�.. � .. _..._.,...-�..-..._...... _._.,......_ AND/O,R..OR,AINF164R_....__.,_.....�_"_"_` w WORKTO'NVG5E5[MER:«..'.•.... . . . ..� —Zi..:. i HOME OWN�;R-BUILDER DECLARAT OVERFIAW SEEPA6E PR.ORAINFIELD ' CESSPESOL❑ DRYWELLC VAL E1fTN..CE55POOLDRYWEIL.M/�NNOLE - - - y affirm t�18t ] 81I7 exem t fi0lfl «le �TER,REPAIRONABANOONNOUSE A�TEH.NEPA{R.SEWENOfi I P I SEWERONDISrO3AL6Y6TEM SEWA�EO15P05/1L5'lSTEY . Law for the following reason (Section ' •po � �� � �• � � -� _,. . ' .. . ... . , .. ... .. .. �. { (RofessionsCode): w�t� ._... . .�..... '... .. .. . oiscoNnecTrwGiwo... ..... .._ .- .. . I ' STX� - ABANGONMOUSCSEWER � i HER- YALKFILL.SGPTICTANKS❑ ..�. . �s owner of the property,will da the H �.e- pWNER'S �- Permit � �s SEEP Prtt57u cessvoo�s -� - � cture is not intended or offered for ; woa a,Business aad Profeasions Code). siGr pUTH9.RIZAT�S�N:. .:TOi�4 FEE��m.. VAEIDATfON- ' CpMSTRUCTION LEND[NC AGENC ` ��` -� •` �'�"' �-' ". ..'� _` � PER . . . . _ __.. . ......n.. affirm that there is a construction le� ��yE AT THIS pATF 4 CONTBAGT WlTM THE NEREIN NAIIED GaN- ?RACTOR TO CONNECT 7Ni AGQVi pi;Cw�YEp�X15Til'�G OWELIING � �.�..�:. �� performance of the wurk for which tl A�� TOTNEVUBLICSEW . ' � �Name 7,Civ.C.). SIGNEO TFf45 . .....OAY;QF. � . . �� . . ...... ._' . ........... .. _.. -.�V���ii i t�j . CIT' OWNEROR -� � � � ��-- -- � � ' OWNERSAGENT �� � � . _ ' .. Address ... . � ��� ■.L IG 5 i .. ..- ; �ooRESg r� n «- �->ruz. � ' tfISS � ttBVe read this application flRd S[ ANO 9TAT[THAT T�ME Ae�VETS COqnECT/�ND AGR'EE TOLGOMPL� - �_�y���` � �formation Is cortect.I agree to comply wit ♦� WrtH ALL CUllMY OwClNANCES ANp STAT! LAWS.PEGUTATING � � _ . , __ � PLlf VWMBIN6ANO56WfiRS. ��1.`��.f...... CS and SIYIB �3W$ regWating Glec[rical f XEREBY CERTIiY TMAT 1 AM Pq0►ERLY REGWTERED AND/OR utharize re tatives of[his County tc LIGENSE�AS qE0U1RED BY l05 ANOEIES COVNT!AND STI1iE OF � � � GKIFORNIA OR TMAT 1 AM THE LEGAL OWNER OF.AHO INTFNDTO XE- ......... ..........�..... .......�......... ..... -mentio pr erty fo spection purpc SIDE IN.7}16 ABOVE DESCRIBED RESIOE LPNOPE�. � swNwiu� .. . � ' � � . . .. ................. .. ..... ._�. ...� ureof ermittee � �FPERMR7EE �e�� ����'�-�'" � vu� . __ .. . � I � � .. � O � o� � w��yi.._ . � � . s.� t0 v o`,a E � m.�o°., . - c ' = °i � °�'r.,d� °' d x.. s3x ' d �' o+ d ti" ��^'� oc�`=�os`a.o ,k, oao ; � o3i3 =� � .� E ' • r'e c y`�„4 � �„"`^„ O M �^ ^ p y u .. n Z �s � y � � e n"' Z. ° ° ° m� � �` �s o, - w=. o�� � r'�►,�,s ~ . 3',,, �+ o OO � � �++- o �'��? v u C �0 4 V �.,c°�� h o;'3.-• � �. �`'u o '. a a O x'o�n,� =�4 �fl-°' y ';;d a p � 7„ �=� =00 °-0°' n� 5vy " m= '�o `� y � - Q 'rJ,R, C S y � c�i c = ty �o,:',o a '^N'�o .. � O � °= o a�;-7 0 0. n,_. � p � o'cs'�s-�= " u ¢F .. 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