Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
1188A (5)
i , . � � � WORKERS'COMPENSATION DECLARATION ; � I hereby affirm thol 1 have a cer�ificafe of consent to self . ' insure,or a ceriificme ot Workeri Com ansation Insuronce,or 7e�a�zo Pa,�f� ,„3 ,��n�,��y�, C�¢yBDe(NEv.B/B11 APPUCATION FOR PERMIT �Certified topy�s hereby furn�shed. SEWER.' SEWAGE DISPOSAL _ ❑Cer�ified copy is filed with ty,buildin9 inspecrion COUNTY OF LOS ANGELES BUILDING AND SAFETY . depanmenL . Dare Applimnt � FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTI FROM WORKERS' y��iw� .z�t o ' � COMPENSATION WSURANCE �uo�tess ST^r�or+ TO o��rH � (Thia seciion need no�be compleled if ihe work involved by the � . nyyN�aE�trt[NCE �.t 3�,�Q uwtn � permii is for one hundred dollars(=IOOJ or less.) �ocaurr U �a . , r�..r�sr oF Cor�cnoN �r�c7H Frtan� rrt '.I certify thot in�ihe performonce of the work for which this caoss sT. v, cuwe P.L M.L fO P.t. permil is isaued,I sholl nol employ any person in ony manner - - eo es to become wbject to Ihe Workers'Compenwtion Laws. o�qK co,uv�v,rap, - Poe n°o. . � . • •... . . �DDRE55 i V p O I iRUNR PERhVT N0. 0.0AO PERMIi N0. I� B Date Applicant � NOTICE�TO�APPLICANT: If, afrer mOking ihiS Certifi�ate af � ��T ��� ,�/ �� � PfFIDAVIf WAryER EASEMENi RKORO.INSfR.NO. DAfE Exemption, you.should become subjecf fo ihe Workers' ,� Compenw�ion provisions of rhe la6or code,you musf forthwith oexitiviqra LOTNO. HWY.OR57.WIDENING . � comply wi�h such provisions or this permit shall be deemed lBVOI(Bd. . &OCK iR��T S/AiEENCI7pACH.M(NT - � LICENSED CONTRACTORS DECLARATION� r.q.pr�pss. veaa�rt no. s�ZEOF toi NOW oM t07 I hereby offirm that I om licansed under provisions of Chapter �� 9(commencing wirh�Seclion.7000)of Division 3 of rhe Busi• g�i�i�s aaac.[s . ness and Profemions Code,and my license is in full force and �pryNECf10N CMARGE FEE � eHec�. .�. : , . � coNrvr,ctoa 'Z a d � L� NumbC �iC.C�OES ��_ � ApppE� NEIMBURSEAAFNT f(E � . ' o f � DO18 �� � �I DO,� Di51RKT NO. GROUP MnP PQOCESSED BY V OIY .Np. IS /� BK P6 O ❑ am ezem t under Sec. of�he L.A.Co. �A� ���" � �V �� ��S P ��Ns�no. b cuss � PlumbingCodeand/or5e[. ofihe �' DfKRIPf10NOF1M7RK iEE F�NA� W �aussewFacor+r+EauaeTo / j�y DAiE ,✓� VAUO ION N � vueuc sewEc z B.8 P.Code far Ihe following reason . gv�i�r�we,s�v�r,E vrt at . ��N�i � � � . - vnS.IND/ORORAINFIELD �� �` � ' ' ' ' . .. �018. . . . MOUSE SEWER CONNECTING TO Br ��'C0. %tIVATE D45VOSAl v � Signalure - CONNEC7 ADO�TiONM&�G.OR � - , - �- -� OWNER•BUILDER DECLARATION wa+K ro w�s[s¢w¢c OVERFIOW SEEPAGf FlT.DRAtNi1Fl0 I hereby affirm�hat I om exempt from the Con�rodor's License e�,c¢ssroa,qrrwEu.nowMae . . . . _ . Law for ihe tollowing reason(Secton 7W 1.5,Buisness and Pro- ur[a,aev��a oa wgnnooN'qus[ __ `,.� 1.�a� fessions Code): s�wEa a+oisaos�t srs�n+ . . ... . ❑I,os owner of the properiy,or my employees wi�h wages as � �!o.� .�� T� Iheir sale compensa�ion,will do Ihe work ond�he strucWre � - is no�intended or ofiered for sole�Section 704I,B�siness OWNER�$ Permit f J (S� � ` •2 7�5� and Professions Code). � --� � ❑I,os owner of the property,am ezcl�sively con�rac�ing with AUTHORIZATION TOTAL FEE ,2 •o�2 j.6�� � licensad confroctors b consirucl Ihe projett(Section 7044,� �qqyE nr iM�s o.4i¢n COIVrRAci wrn+rME NeuE�N�wNFo CaVta crpR To � � �� n[� �- BUSin05s and PlOfC55iof15 COdBJ. CONNECT THE ABOVE DEXftIBED EIUSiING OWELIING TD THF 7U&IC SEWER. U U{[5—8 6 CONSTRUCTION LENOING AGENCY � - � � ► " - - I hereby affirm Ihat there is p conshuction lending agency SIGNED THIS �AV pF � 19_ for the parformance of Ihe work for which this permit is ��R� , � ' - � � � OWNERS AGEN7 Issuad(Sec.3697,Civ.C.�. � ��u Lender's Name lendar's Address � . � - � � I certify thm I have�eod this appiicarion ond stme thai the - above informotion is correct.I agree lo mmply wi�h all County -� -� - - �. ' � • ordinances ond Sta�e laws regulating Plumbing and Sewers, - and hereby outhorize representatives af this CouNy lo emer � -�� - � - � up e bove-mentione�.psa erty or inspeclion purposas. � �•�r�s ��oZ�a s�1�b�i'�5.6 . � Siq ure of Permittea, � Date � . .. � 3EE pEVERSE FOq E%PLANATORY IANGUAGE 7 .�1.�_ . . .. � ' .' a, ' ' �•� . •r 's ����� '/ . � � � -�,,�� � . _ ,. �,.V. � � � � ;�; -a:$�'�'�`'��,,� '� F,�� ��' �, � , � .,! ;���e�� ���"a'�'���, �,�• ��� ��� .. . ' o$ � �"`�e�'�+ ��9' �'� T'� �}�� .. . O �F �� �� ` ���� � ��"�1�''�� -�s S �� s ��� � � ��~ ;' � . � � d z� �a . �L�. �r ��«Q „ �� .� - .�i�T • � � G�T� �!� `" .. ;�'v � � r� . � ���� ��-S- �_�5 � � � � . � . . � � �� ��. �q� � � � . � � y: 'Z ..._�3 'Yi a �i� O� w . � . 1 ��, � �'� V ��^�'eg��8 � �'� � � G� � . � �i. : . (,1 `��v 8 ,��o� "� ..o�d a�- ,� �� � p; � � . . - �"" �,, .:��� ��;��' ��� °�„ ��' � � sd � G . ; p, �d���$��y�,'���g$��d ��x�° �3Q� � �sa � `�.M� t�/� �Q S+o�T� � 'P+�G.�. � ��� ���'��a ����� �"�j���..t{�qr���a� ; , ..• „ r '^ �3 �i� a.•� a����� ��� ��y��� „ ,. �' $ X °�Q.�`°*'� � ~y � O • 'a � � �3�� :'i . ., , _ , . ,. , , .� ' ��� , *• '� , 'r , 1 �� � ~ t � , t\ O yj � �.�•� , Z� l �r ✓ �• `,l G , ;- �' ` �:, t .. � {,�, ;� . �, '. .,y`, � ,� , , . ,1 - , , :, . ,. � - � • " ' • W . .!. ', ' . . . �' . . � OZ ; W� , ' ``o `\ � , .. , N , �\ , . , � . .. � � � } � \ ., , ' � �Q �. '. . ' . , , . . • p .. , � _. . . o "' , . � � �� p� �,�� �� � , � � o � � �� � ������ " , � � - ° � s�. ��� � � �� ����� � . � ���� 3 . ��� �.