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HomeMy WebLinkAbout1518A (8) 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���+�e��'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..ti�!' - -.-V�•G: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 n suc�+ pro�isions or +h.e pe�rm�'snoi' oe deemec.' I�IWY.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$6--- �1ta Loma ,F.N�714/980-4429 CS'RC'.\C 3R06' .NJ CSScJ=Y �Iiv _I om eaernpi undc•Scc_'_""" _of•he i A Co. `'`,T: '---��/ p �7 - _ - /(� ek vG o ---'- i,.,�;r n:) Y1412.�l_.-----r'-nyc��Q _ r✓ � �:: '.;F'aCR�T D�7F vV,^,7r °Iw.�br•gCar'cor.d�b.5ec____—__"_o��he _ -:: �.�i V �+ri.s,-��.ti=e c�we:.,c=a —� 1�00 '"` 1 0-L -`a L VALID ION � B k P.Cocie for the�nllowing rreson._..._—__-- - '`�.�..�"[" " "e=��--n+:t �:Fa--:=oe -- 2 �•- �a ax�in:,u:n^ :�� ,� � Dnte__ ''�� -- ; --------'- .�=r S:,F�ro•.,::Tinc:.;; a , i �:� . - .......:,:n'�^Ic;'a-,c,::;�c•:.. r�-�--'-� I S gnc•u.e.._.'_..___""..'-""—'-' .__'- __-- —"_'a-' - OWNER�BUILDER CEC:ARATION _� ,_„ _ . , . , .. � ,..,. .:�_...,,,..;... I hr.•r.nv pf(irm rha'I am exertm�F�nrvi ihe Conhoc'a(s L�ce�se ���� ��� ��•� ���••..�� - . .. i, � .. ...�. .. . -..._..-'""_ " .. . - .,. ... .'� `J�,�-�r Law(or tFc=cllowing recso�;Scr'nn 7031 5 3u�sress a�•d Pro- - � �. � . .L....iuns Cod�• , . ' �-'--....... . .. , .,.__ .._. rr a e.o m '� Ci i,ns owner of+he proneny,cr rnv employces w��h woc�es as ,_,___, ______�, j �$-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':. u:.�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� - , opon�he obo�o-r•+��nt�onr.d 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:��—,-�.a.��,.� �,. ,.:; . , ..�. .. --.-- 'r�r- p �izense Law for e �. ., .�.s.r:,��vtau•:: .' � Jy— _.'_'_.'__-"-_____- ' _'__ ''••• I ,�.,•v;�..v'..i:GPtdCtOf�s �f P�CCSVOAi.�T4'�pTp INSTcC'OR"'' NAIURE _ __. ......... __ _____ IL2SEL`y'7l(�tYf3N, �, , -___3_'-__ �11��q;.a7R'Ip�•:'�:.�.ih:n1(";rlf!Y 7D3Y.5. New�ou�sewers �;+;;�.:..;I ,i i ttsa�ass a�d�re:',� �., :'::..on; �;s, •�� ::••coain8y � ;.. :': CANNECfAODITIOkA: --_._E.._"_'_' ` -�-� --------- wbdch veqv,iras a���:.�;�r s. :.�:.sera:: :':,.,: '.��aprove, � BVILDIIVG UV 1VOR% ' ' . F ------'�-- -'� demvJesB mr itafictr>,ny s:m:d:tra:l�rdo��ta:h issuustte, uaric Tntix,seev,v:r�s. 1 �"----��- — ------'---'-------"'-"-..�--` - --"'�'y�e����! nt rar;•:ck��m>:7t 2o fdl'e ' nnoio�nzaiN�iu n � . .,ulso re -G7 s ica a �. - -----i-----•.------� ----.-,-------.-----.�.-------.-------- sig�ed stetemeraa 2TiC¢.4a i3 ticcfucrd s:a:smnnt&a tbe . cFsswo� i=! uurwt.�❑ � � - . . . ,___.. . , - �__�^_.^_ proutstosis of�¢he�Contoac¢or's L'uense�o+u(Chaptez 9 � AITCR.REVAIR.SE�V[ROR'_-_�_'___"_i _____"_'_____"'""____- __"__, �CA9HJYl�A4`tJ.i,4';v:tfl.Tt..$tMb]Q�aJ 0f��'Wd580O�Of t� ' SFWRGEDISMJSAISYSIEM �9.�.. —'-------'-'-'--'--' -- ms Godol or R$a&b�6s oxo»tQt . x---'--._.�.—._ 8rurwra.r a✓.d ofesr.i 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- � �- � BPR:IOPB.�.dsa.«:x Lvrc�.'.ocs :.n3:ep_r"ly So mn a. 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