Loading...
HomeMy WebLinkAbout1517A . ........ .�M� .,... . �� _... ._. .„_ .., . - ..., . .. —,—m�.,..., . ..._,.,�e�..�.,._ _...__'_ _. _ _ __... .._ -,—_ __... ._ . .� .. ,:.._ . ._a... . _ . _, WORKERS'COM�ENSATION DFCLARATION . -,.. ,.,,�.... , ...._,...: . :...:.... .. �.. .:U•, . .-.: ...-�- . ..,-n.� _,..�- ,.. _. -. �j . 1 hereov offinn •�,o• � have a ce . , , , . •.elf 75at`n2tl�� �, . .. . . . . .. . ._ ., .. . .��.. .� .,y� . ...� , .,.?�: nsve.or a<er+6rore cf Worke�s C. ' .•.r. ' -, .. .., or ce eoe(xev ais+i ' /� j�+� ,T ,�� a cen f;ca ro y''^.erecf.52c 3800 LaU C; APP���ATf�/N �`V� ��'��1'�n4�I��µ'�MN'Y�.����µ'��`� . Poi�,, �7/ �yry c�mpo�,Y_St,�lund ._.__._._ �� SEWER SEWAGE Q�ISPOSAL � �I Cert NeiT . 1;^��erehv furr Yhed . � - � • � � � . � � - -' � � �-��� � .._ . � ..a.:..a..._. _.... �Ce�i'ed�opv s�led Nrn�ne cooniy uuddir.g msnecno� COUNTY OF LOS ANGEL�5 BUI�.DING A�D'SA��7'Y`����� Cepnrt�r:t:nl . . � �.� . . ••� �o,�.��.2��8FjA�,�i,��,,;FregIpari-.---.-- FOR APPLICANT TO FILL IN ___ CONNECTION DATA CERTIF�CATE OF F.XEN1PTIbN FRbM�WOhk�KRS' � s,.r:•.3 �,,�i•p��, r'�-�3,n� 7j� ;n�p'. ^r�T� COMPENSATION'":S'.:G"�,^� .. r.:"-"_y cTl�`'%1L�..i.�iGvJ.l�L�1.f.���. _'_--_� iTn�s scc��on�eed no�be romole•n,: . •.,. •. , ..•:,:6y�he 5 Tj��� sv.��o.;kffFiE1:' dFFFR �r.�A.11� �l7.�.21'liL"_--_"' _�_�'— _'_ .O.\cR perm��is for ore bi�rdred dollors fS1W:or�'esa t -��-voFc;rc�=�'a� r`c*Hrae�. '.��iFS� ' ' . -n.. I ce•r��y tha! ir �h<: periormancn oi•rc•.vc�e fcr wnirn :hu „RoSSSi � . ' �CC _'_ -;F._ r�_ .:- ..'- perm i is issuen, I snnll not ernoloy ary pe�son�n ar;y mnnner �a 1 J�fC'� w os to becomc sub�cu�n iFe Wo�ke�s"Compensafir.n Lo�n�s ,:t•.�t�� �1���_��_'^_____ _ ���' "�� � � PV ,UOX �ZJ_____ 'A��K�:3:��:�;, ii:f.i��FN•\�^ Dalc_.__AAF'�ca:ll.__.____. ,aC^k•ti ^ f"Ja•:' l.r.i.:4 -neCN4\' 4iC^i�IA�f'e�.^_ J.>fi vor;ce ro aPeucAn? i�: o+,�� ��k��� �r�.s Cerriicmc of ;.-v Covina -.�� �.8f5�Z�5_4.L f,.�^m'pi�on, vc, .�... �.: i..r:._.:. ;.,...�r. tr. �ne Werke-i — 1� . -;i., / PCf15O�iOr•••����;�••.� �:•"�•�•�... .••�•� yn��niUStlOtt��wit� JF4.P'a�(:'. J"\(: j . STWIDENING __'__""_ ' , ' v—"____.___ HWYOR .,,mpiy wrth si�. .� .......�. v. . , :.•...�. shall be deerr.cA 35"754 -- avaked. � �..;;:�_ re:.:' — ,--- _ --`- '----' '-- - �o:.s ' iICFNSEDCO�IiRAC.TORS�7ECi:4RATION�� �pr:;:No• , ::ec=•.::� _. !herei:v niivm tha:' ' ••� +-- ,inner voaisions of Choo�er ------" _ �:�� . r .,s.ci """' of Divisron 3 of•nc B�v 9 ;rort,.�cr.ing•x:i:, t,,,. ,. ... ;�, ^,�a[: __Jr,.1Y1 _..�'�_'_—___'— _"" ' c-r.a.,c5 � e(.rcnnti Profession5',r.r�. ....�. ..I�cense�s w ful:forre nnc Fi'L3.L.uli�SiQ �i�N�4.�.__—'__—�'__. ,-:_�1rC'•^•�cF�nRO:�:i 6 ( � �I r:`4'KG:�J1 Iri 1 � .ice^seN�i:nL•er,_ 4148�1 __i..C��ss..._C34 — ��:,k�-,� F322�Bee.�9Qc�_.�r_-------- ��.�:._��;.:��.—.� � Co^tro:'orFree�an-----���� $1��,��--.-- �is�Rir-�c oea.�r •a:,N -eo;;�cr;ny V �' 1�t�I,�mB.—_'�_7�-A��9$D-�4�2� f . � "" '� o - ,; ��•= �7 �7 • � I a�n ezertic�r_nde.5ec___.___".--o he LA.Ce. :.hy[�a Q�1 Q���1__ �._47J4 �' I € acy 1 � � ,� �. n; �.[sr:a c�on or�G^tiK�!�:F ;N:.--•------'�—_ W °Iumb:ngCodea^d:or5ec. _� � � ----- — - -------- r._..�..���.,.,m � � o;s,.�.,� ..,..,, :,-. 1� �� n: ��_Z.3`-�.6 i VALIDAT N y ,-.,,, ,,,.�cv B 8 P Codc�o��hc fc�lo��vi::y mnson_ _._._________— - — —"''� — - � ..,>nK s,�:n.;���-ca .�n,,.� � � , . . , �' _��,hr. :.c�_^...a.tl_� — -'— "-- � _i7c]fe•__'___---- ::.�Sl:,F1::.N'J=_�\:�- __ yI—�.::_l:1:.=::�.:__'1!_�—_"__—___�__ _ _—__ Si(3�Or�:'C_`_____�_ . _1•,.iJV:".�Jl:i^7:�1.(f f..'�('�2 _—_ _. � h�J.k"::.::1.`.:<C:�"P � "_ OVJNER-BUILDER DFCLARATION.... . . --�.-_;�:_cc�'„�,�,,._..k,:,vmc -- i..._ �, `�q n �he�P:ly nf�rm IhC.I'cr:exernp''ron•"C CCn•rnrtor'S:�[H•lse :x♦ .._i�<i'1 f.�'�•.r:l '.��rvl+�.:',�_ _� _ - i p. �n Lnw br ih.e'cl:o�ving•eason�Serfcn 7Q3'. 5 Bo��ness onN'ro ;,r:4 .F'�.::�0.�.G���'�oc-�o..si wc`^'.,ons Cr.de.:, _ .[a��, i^Sn�S.y-•• '____ _ _ " c { �l 6 O � os owner o:!'•e oropr.��Y,cr my r.�r•i>�oyecs w:�h wn�•es os + .� �,��7�� •hr,n sole iumne:na�io^ wil'do ihe wor�nnJ nc�s•r„c��r.c ix��or ir�e�ided or ufie�ed for sale�Sec:�cn�O4d,HLS•nC55 OWNER3 Permit � $ ].,� � ❑nd Proicssic�.s Ccuu• — ` �O �'��j:,y�t'�' � i.as n•m�er o�the nro�crly,cm ex:�us�vrly rnn!ran,ng w�lh AUTHOR1ZATfON TOTAL PEE liumsed:ortrarors ic r.onsv;¢t IFP Prnir.0;Sec�icn 70d4 I HAVE l.' 'i. i - CC\'R:�;i:.'.�r,,:..;:F'v�n•.�c'c�'aa;*:�c�r, 11 C,�9"'��O B�:vress nnd o�ofess�one Ccdct C�M1:NECI'1-C A1C.f�"ccCi JF?F%�5_\C-CY.�il\;.';:�1°�:i r..Sr::.f CONSTFUC"ON iEND!�'G AGENC� �7 nv . � ���� , � !:ereb nii rm rf�.a• •no•e s a +onrructmn �nnd.n;; age•uy S:;Nc:;'.!5 �_ Y -i:.N•-5::A � .. Fo� �ho oer?orrt:anr.e oi 1hE wo�k fo• which rhis ,�e�mit is ,;,���,.,,;,c.�•C-�YJY✓�,_V✓l�,(,,:�1,,,,,__—___ issued Sec 309T.Civ C'� p! .�>• -�:[„-f�t�= ' �. :`',1- — lerder's Ncr.�e_.—__.._.._._'—.—"__—___. . . , . . ' , .. . . ....... . . .. ... . . . :rnne�'s Addrnss.__—_..'—_'--_-- � ' . . . . '.. . . . . I ,er•�fy t�+�' � n�c •cad •nis aoalur.'on o,:q e�cie•hat rhe nbove nim^.^a�c. . „ ',. ,.,r ..�romp'y..1��o I Co��iY _ ,. - .. .__.__,._ ,. nrd •cnres o�d c'r , � .�•: .r , Hlurnb nq anri 5r.we•s � .. - . ,.<.._ ...,,_.........,v.... .......�.....__... .........._,..-_ .-__.v.,-... . ,.., . , ._._ .,.._.�...._v....._.........,...._ ...w. .,..._..,.._..__,....,_ ond hereny a•��nor.ze ra•preser�c:���es u` �:.ia Co�•'+ry tc en�er ..'. .,...... . . upor.:hr,abovr,-me/ntinred oror.crty`o�:•+sFeciicn ouraoses. " ' C=�.1�1V1��,�'_s/.1.4W�Vl�U�__'��^�"�.� ..a Siqnn•�r�b1 Ppri�^��tea Dnrn SEE RFYERSE FOR EXPLANATORY LANGUAGE , ..:. .c�xr.wa-.,. .�..�.�.�..�.r..._.�.�.__w..�...�::_..�.,,.... ,._"""'"`___r�_iy.n'.:.::.:.r.:-,...•.:.+:.,;.:::dl'tian�w.i::+r'w,'.w�%4ire3rY�d`.aa2aousvMe(�46F1 1Y1d1"M1aL� . .�<�s�..Y�' . , �ns�Fcraa�s sa+�t�a��_..____�.,.......� � i:W1�TER•P.tis.L�a:ii ryEC3.�.Y3i'sT�O�i ,..�...,_�_-;.�.. '�:.'-�.�n,.,�-.�.� . . .---.._..._.._..__.__.— „�,..; .. �....,,,-,.. �'rd�9����3.5'j I �DATE M InSPi.CTOR'S SIGN,4Tl1RE _._____'_"'_"_...'__",.__..__'_"__'____' 1 ISYi'tOY BYtt:�:Ll$:f>1N.1:%Ct::j1i it:�Y:1 1llS.e..O:IYY&CYOP°6 L- � I.icence I.sa�f.:r::�+ ifLiOJ/YYIF Y'CR�C.".<S[:.S:nfd 703T.5, NkN/t17USF5'WER —�f�'••• �W' !°�;'�%� . . � '------'--._...'--.._�.,.--.T__=_.'._-- -----------'- Bresines>• »ar.'W.•.n�issicrei Cr,r."^;, Jlu;� �is,� rsr ebac�Ey CONNF.R n7DIT17NAL � � ' ------ '----"---- whleh.^aga:.-as r-�rrr;i:�:c rn�:rrsec:,a�?�er, emprorre. ., ' BUILGING O4 WORK � '__________ I�CMOlf3/J.!1Y fC�:1`S�Al L C.iYL'LdtiT��}�'f`JO)'aG:.'TS3/lR91C@r ' SEv!,C TANY..S•EP.�I:15) j _— '--- --- ' �fSR YCr7:�%i'C: :IJ!• )]l,biiCtliS3 JM'3ti�f�dJ:eF: e0�8I6[d �.N'J.'OR OIY�:kFIL:O � ecssvoo�[7 oavwn�p i --'-----'_--- --� -- aigncw'siu:rraaei:t tiwt S:r s lu�ar.::vt�ure�ssescx ta� ibe . ____ ; ,__ __� J prnvisennr nJ e1 e Contra.:Bcr::r.etarasc l::e::;1G'h�a¢tsr 9 AI?ER,REYAIR,SFWER(]R ___________ In%�-'MCNptl�'w,ith. .Sscloio,w ;�OL'J r,J i::olsrun 3 oj t%e 1 swn�c JISPOSnL SYFTEM � ---- ' "� " i$pA41fi8t:.Equ'PC`J�(KJitr+tin .;�uaJ r.r ibnf,bu fr axempt ------ _"—_ �:SCONNECT F.UG AND =hCPCfvvnc snrw a:ac's:�;i..Jo�xhv r!:!'y"G:Z.?..'S:!i3..i�dBC'A.A9D'y .9BAN70N IqUY:af WiR I --'-- --"_— . . . � - GCKfI'.:SEPTICTAAK50—_—' ' ---__ •Jt6:A:iGi.Of.S4','ii::�;.'v31.11'�•5R,/:Ivii:�e.*,s;c�rapaaynf6 �s���,air�s❑ csswaxs;7 ! ----- srsfj��e��tbr�;.t�a�a,;x•t�r,a cwo'a'dexrei£�;;i coi,r...ve Sbmn ��.. ------ ----- • . - ,�.�='__�r:.-,:�.z-., .,...:-.. � ' .1 . . j��i;R`4. :.1��:�l.':G+:�.�•1�,/:!i.. . � •.. . L_�e..i!'la":1\i:�:.f' ,�. � .. ....�i'4L':w.:.�lU � _ .�__� ... . __ �_ ' '�II:• .iJi' IY�i�R�..,�1[:Cl:,f`•,.:Y�n �:�I�r':11•. . � . . � . . . �_ ;Sac:�70tiY,�.*�wres.ss�uGd d''ar;f_���.as�;Godc: T.+""""ox- . ' irac3ur`.: ;.i�rn�,::_ f.st�. ,'vsas .scn sprd; u.:,:n e_ 'of - -- --- Dr�pe'r<.>•;,.�l;o.#wilcf��ur i;�mh�rxc,tkarsaa.anr.'uboilaes , � — — -- . . suc6 tc•crP: 6irr.aclj prtaided �a�a�::s:i �rr.�xr.vevne�a# � _ csa r:ot:s:Renzad nr ojJarere'ync��suie.?j,ho+�uves, the -- '— ' hrsi�iag ar irs�:ro tunen: 1..-snl:f ni�:,i,: ane ye�of .. � . r ' „ _.__ eamfiletiott. anc ��xuner•Dmzi�e:^ .ty.: i:r.v:: i:e brtfden . . • - . �of Prouixk �!.kct�e Cad xiut b.u'x�.'(N•lYM.jl9'C'N_�.fM LX]¢ � .•�. . . . �„ . �f1/'O,`A4C Of 5llYC./ . , , � ., . .. , . A . . , , . , . . . . . ,�38'A 27:�P.ri�ik t7;lie'F'.Y."1kC.�.—'---'--' ' . ..y.. . , - - . B�c�t.v.�OY'tL11B�4a5�1�.___._.��� ... __—_ . — I1iaYf:_ . __.�__....._ , . — --•' — � C7�•aet ----.�.��__._._._ _�._.�._.,.._.___�� • 3;�S�sGrtr�'s wores . ,. .. ._. .,_..-.- -... .......... .. . . .. — .. ...,...,i.......�,. .—. —, wr-4'9,.w..Yr` ;. Mnnh.n+i^s.�+�....-rv,..,..,wo.-�¢....,...,._... ,n...u��rc.F-u4.�..�.-...�....,..�q.M.�. .a+.x.,..,, t..n :,....a....n.. � � , . '_�_ �' :..1•rfJu.,.L' .�:•,:..,5�.::+i..�;;,,J:.��*�wh.. Ru•ail•�,:^�'.,�a':;.0 �.. ,.,,�� - . . —. . . , . , . ,,.. r . ,—.. ,a,.rv ... . ,...y.. �,,. .v, ,.... .... . . ,,.