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HomeMy WebLinkAbout1518A WORKERS'COMPENSAiION DECLARATION � - ' � -� �" ,. _ . �,. ,._..,:- :...:. .... . ....�..� , ..�-:;.�� .;�, ..,,- . . .. . ,. . _.. . - I here6y oif�rm :ha� I hnve a certif�cnte of consent to self �.`�.����". ..�...- ,�..�..,.. .:��:. ����� .`� . � . '.:. � irsore or o certi�iw�e o�Workers'Comaensotion Irs�rance or �"•^�'�� � � � � Po�;,'No` ^��SmPo;;�°� ,°�nd,-- st�.te._._ �s�:r REV e-a„ A�PLICATION FOR P�RNIIT --- �— --- ^ce�,,+����'y�: �rn.by f�rnishe.d SEVNER - SEWAGE DISPOSAL _—���iimd rnoy is f�led w��n•I�e co��,-iy bui:d..�g i-�spec'ion COUNTY OE LOS ANGELES BUICDING AND SAFETY"" " " "'"" `" dcpa�tmcn� . . . .. �- . � -"__' ��+��_8�20�8�ar�'��o���____1�'T_PP.ma.T1 __.._..._..- FOR APPLICANT TfJ FILL I!V CONNECTION DATA � CERTifICATF OF EXEMP?ION fROM WORKEkS' ewtoinr� COMPENSATION!NSURANCE AODRE55 sTATioN oecrH , {Th s ser:o�necr.no�be campleied if•he work involved'oy Ihe " � uavpv or.rm:i is fnr or.P hundred de!icrs i$1001 or:ess.: -;:c',�'� T A '-'-------' '�.-���'.'��Fr`:•:^� .'__ -ea.ex ��. ._�.__-___-_._.__ � N::.���' - -.-Y�:C:C::ti�C.^,'::\ .[fwlrl FRCM , � CP.'ti�y I�`t�' In �ne• perormnncF O�ihE�Wn�k�Or wh�Ch ��+i5 CROSSST V. CURB PL M.L.TOPL � � PCIT'I rs•ss�ed, !shol��+ot cmp�oy a�y persor�n anv morv�er 50(]5 f0 i:[iCOmC 5..6�CC1'O'��[:Worters'Ccmpensa:ir.r�ow: - � � rC rvo ` � OWNER � �ry.� CO.IMG.NO. JOB MO� CJ�'�� ADDRE55 �V_3Jllll J�Z7._""______ "i'..\K�CkV.'\C 2.7?f,+N".•'\� Ua•e_— AuoLmr�..------'--" — (] A NOTICE TO APP:ICANT: i� afie� mak�•i� �his C2�•i`�ca:e �- :.,. Covina -.,� 838/967�'75Y� "-`���nv�i .o.a�.E+ :t.i:':-v' .[:.�.; �5:+no ::n'= �,�.�:^r^.n!�on, oou snauld become s��b;ec' te •��e Worke�s' _,,,,i -- -- — � �pensa��on nrovisrons ai ahe Labrn code you musi forthwdfi 5�,gii•ii�h �c�r��� ...nply wi h sUcF 7ro�ision5 or 'h.y pe'.rm�:Snn;'. oe tieemL'c Hwr.oRST.wIDENING �Cvnkt'0 `•<_"_"__'ia:" _._� _1��4__ '�'f_NCHOACH.ShENT � -'"" . - . , . . '�.NY".:: LICENSED CCNTRACTORS DECLARATIOV '��^�;."`+S iv.e�_.;, �o.V�^._o' � ��eroby nff n r,n;., :,,e, , :r .�,.;.•..,. __-- _--' — ',,,,, '. , weOc � � :: 9 .,,. , .. . .., .: � euaoir+cs ,.5131 $@ 3 cHna�es . . , . • �r,�, ••,..:...,,., ... ',;,:�r.,oncr�-,y licenu�s i�i iu•i�u�ir,u•ia P��e��� ,t _ CONTRACTOR CONNECTION CWSRGE FEE �.�«�„��N„�,���•---474887__.� ❑oss.._C3Y'__— :.�s:eia� .r.u�.:eti:�r�-=.p � 8225._.BP�'chwo4c�_�I'..---------- ----- :.::,:. - v c�,�„���o,_.�s��a�-----�a��_8124L$6--- �1ta Loma ,F.N�714/980-4429 CS'RC'.\C 3R06' .NJ CSScJ=Y �Iiv _I om eaernpi undc•Scc_'_""" _of•he i A Co. `'`,T: '---��/ p �7 - _ - /(� ek vG o ---'- i,.,�;r n:) Y1412.�l_.-----r'-nyc��Q _ r✓ � �:: '.;F'aCR�T D�7F vV,^,7r °Iw.�br•gCar'cor.d�b.5ec____—__"_o��he _ -:: �.�i V �+ri.s,-��.ti=e c�we:.,c=a —� 1�00 '"` 1 0-L -`a L VALID ION � B k P.Cocie for the�nllowing rreson._..._—__-- - '`�.�..�"[" " "e=��--n+:t �:Fa--:=oe -- 2 �•- �a ax�in:,u:n^ :�� ,� � Dnte__ .:.. -- ________" .J�[':,•F4 CO•.�:�: a . �:^ . v . IAG:•^ I .......:�:i1'='IICN`�r./:Gvc•:.. � I S gnc•u.e.._.'_..___""..'-""—'-' .__'- __-- —"_'a-' - OWNER�BUILDER CEC:ARATION _� ,_„ _ . , . , .. � ,..,. .:�_...,,,..;... I hr.•r.nv pf(irm rha'I am exertm�F�nrvi ihe Conhoc'a(s L�ce�se ���� ��� ��•� ���••..�� - . .. i, � .. ...�. .. . -..._..-'""_ " .. . - .,. ... .'� `J�,�-�r Law(or tFc=cllowing recso�;Scr'nn 7031 5 3u�sress a�•d Pro- - � �. � . .L....iuns Cod�• , . ' �-'--....... . .. , .,.__ .._. rr a e.o m '� Ci i,ns owner of+he proneny,cr rnv employces w��h woc�es as ,_,___, ______�, j �$-7�V !�•ev sole<oinpr.nsalin-+,vv�ll do tne wo•k nrd thc s'r�rr�re is�r,��nre�ded o:oficnrd fo•sa�e iSecPon 704d,B„s�nes's _ond P.oicss�o:x Code` OWPIfR�S PermiT--r i �C9 e :�.o l_%,b ii.'.xi _.. !.ns owner o'ihe nroper!y,arn exc.lusrvr.y cor�rauin AUTHORIZATIOI+1 � 'Z Q 5w"� TOTALFEE 1}�;�9y�b hcensed co.,�rac•r.r., .., yr,.,.� .,. ...r�ro:ec•'Sec'ion 70d4. ,r.v;r:.••�i:s'�ar. c:.C•�'anrr!.'i-�.=.+['s�.n\nV•.:CJV447.T,^.C':: BiJsirCss Olitl Nrn�C•��•�••.;.•�..••� ::i\\::I'�..4i!:+f��:(i J;�:x�:!�f:I::.i:NC�•.:�i�'JI3.1'.SEriC2. � CONSTRUC7!ON LFNDiNG AGENCY 1 p` � ^meby �f(irrr �hn� t��ere is o co�s�ru:l�on e^diny3 ogency S!GN:U1h5 I]F�c•�_ � _•p8 for �lae pe•4ormonce of �I•.r, work fcr w��,h IFns perm• �s `�'����''' ����,rS�•• �ssucd lSe� 3097 C�v C':. r;:.�rk,>;;-;----P -- ,�.io:... ''=.h-}C � a±t-V13- Lenoe�'s I�nmc Lenoc:'s Address______ ! rern�y iha' �h�'rve read ih�s nophm!�on nnd Yoic thm•he � � . .. aF:ol�e mio•�nn•io•:rs cerrect.�agrr.c Ir,wm;>ly�.v�•��eL Coun�y o�dina•icr.s cnd 51,^.le iaws requlcunc P!�rn!!�ng and Sewc�s. nna hereby ou•hori�e reoresenk�•:ves ci�h.s County -o ente� - , upor.!he nbovo-r•���nboned prooer'y fo•inspect,on purposes. �--��_�llx.�,tAt�_u�.��._ ._�'�`�-�'Q'Sa 5��no��m���r.•�ni!rF:e Do+c SEEREVERSEFOREXPLAPJATORYLANGUAGE ...__.___._.______._..,�._,.m._�.,.......�,.._._._.. .__.._.._. . i3�.iPC{1'CR'S PIQY� " d�F�NE12-B3LTYd.I3�+12 DE�Lkh�A"d'YQN , ,; . , • ' __....��.�...____.n,T..__,_..__._.. . . , v;9. ,R:- .�.a..m����_�9�-.t.T-T—,-�.a.�..,,..�, •,. ,.:; . , ..�. .. --�-- 'r�� d � , . ' ' ^ ��P�COVOAin �nTr��iNs�c-oa•s;��YNaroa�� _ u._..,...,... . .-----,---------- Ih2rebyai#i¢�a;,..e( ,:, �vtmi::. .. ..v'..::r,�xac¢os's __3_'—__ s- Li^.evise Lawfot t�u,r n::a�x•i�i�;:•�:'+.;',���:it^:!,•'r!s 7D3Y.5. New.�ou�sewers v;;.',�.` I ,�i .. .. . -�=:,.�� `' ,�ttsa�ass a�d�re:`,�.�.s.:.r, ..::..:r:� '..�, �� .:••coain8y CANNECf AODITIOkA: --'_i-,"-—� � -�- -----------�---—�-�---------------------- wbdch veqv,iras a���:.�;�r s. :.�:..:er.:,: :':..,: '.��aprove, � BVILDIIVG UV 1VOR% ' ' . F ------'�-- -'� denrv�/i.s.8.,,t�m.,r,�,i_tafistr>,ny s:m:d:tra:l�rdo��ta:h issNrsftte, uaric Tntix,seev,v:r�s. 1 �"----��— — ------'---'-------"'—"-..�--` - -- qteires t�ie����! nt rar;•:ck��m>:7t 2n fdl'e ' nnoio�nzaiN�¢i n � . .,ulso re -G7,s ica a �. - -----i-----•.------� ----.-,-------.-----.�.-------.-------- sigs�ed ste�enseraa 2TiCa.4a i3 ticcfucrd s:a:s::nnt&a tbe . cFsswo� i=! uurwt.�❑ � � - . . . ,___.. . - �__�^_.^_ p�ouis�osis of�¢he dContvesc¢or's Edcense Luw(Chapeez 9 � AITCR.REVAIR.SE�V[ROR'_—_�_'___"_i _____"_'_____"'""____— __"__, �CAfH�S�A4YJ.i,4';v.tP�S�c.eema 70¢70J of IDivisson 3 af tb� ' SFWRGEDISMJSAISYSIEM —'------"-'-'--'--' -- ms Gadel or tbat be 6s exempt . 1.'_""._._—.__._ 8/i.StNC:.t 4Y.t1 x4V'O�CSIf DISCCt�NE.^.T PIUG AiJp � P.�C/Y!�I:11:..A.l:.�l i:rv �I�f:: :i:::'.�iH�.,�ry%i'.::MO::':YY..:�:e�• . ABN\DONH�USiSEWER "—"-- '"_'"__'_"_.__" ._. , . `d, . : BR:RFIII SE�TIC iANKS❑ "_�--- --'_`.__'— 9)iCS4eFl:•::!��ri':!.'ia ..s,,i.l: �•t�llhitL.^..t'�IIP::h!y`::�'i • ,• �: : � sanb re:. .. c.. .. ,snc./."�. ..,..�,n�+,:in.: . SFeP.PIf�S L.I CESSYWLS u ; � � _ _ fl '•.u!` i.'. : . , - .�x.�r�x�cc,_--..�.-_-. ., '-� �. ____._____'_S.___ _____'___'__" �4UC.7..liGr.,y,/A�,•.�l4l,:•�•�''�..�.,:�, . , ... � . _�_ . , _ n I.as iSc owxs�aS.hc r�;a:;y vn➢:.-'.r.tii�e was&,and , ,-- , .�. . � . • . � x�e s.,•sr.are 3s:.0's�tcndea�s ncierEx:aor sale. � ' �.�,_.__. fSsc. 7D4�.Bws:.,rss sn�S nro/eesiorz��Crdee Tk�"^�.ost- � �— � 83M:IOPB.�.dce.«:.a LMrc�.'.ocs :.n3:eQ,ly So m�a. �oy+' — —'— ---------- Proper.v r�;�r=bail•.�'s ra:::?hrnvw..c:f,orarya+.orsd wba"e8oes — . .. . aa�Z• wcek 5ewese j�5mvidc:i;;l�rt.sasi; imQsoverxe+oSa _ ,_ "_ srs uot s:�tc•r..e�e�:or a,ffareG for�ale.3'I, dsowever, Rbe , ' � Sa£iJrnx n:� :rr:!rox•2.r.an:i i:.:oid uritbix ame`yeur aj ______ _�.._�,__._""_� . d'OflfplKliOh� iLC JSdFC'w:LieGLY :.l:4i[�i.�V:: r.C^ �3°r!:LA35: . . q:�:tiVf:4t�:.r,i ise di�xna 53:srsl or i��:;;:%.s:;,ror ehe ' � — --'-- — .--..__.��.,_ _ �iufflace qfdCi$.f , .. ;.(.-. , . . . ° , .� ..,, ,.� ... ... .. ;'-.I 8II1��E"&2�h�5%Y152dC:Y.�f�•--...._.,..._.._.�-..._.._� . . . .. . ..., ,.. . ,. ' ._, t` .� -. .. : ..._�..T ���.li.�4T t,j1LS Y'P1#SOXd_"__'_'...'_"""_ �. . .�. -"----'---._._ � �II�� _ __ --'—..�_._— �..._�_ C}W�*C'P,_"W.— --..,..__.— .. � �,..�.__�..._..iNSPECTOR'S NOT£S "_.�_.,... � . . . . . ... .. . .. . . . . . . . . . . ,