HomeMy WebLinkAbout1516A (8)WORKERS' COMPENSATION DECLARATION
hereby I '.elf
,nsuro, o• . •.i' , or
a <e...fiev ggg�s'''TTT''� .., . 3'. ..
Po6cv Nar, yOJ �l "r •`,'-)t..•. unc --
VVlCer!if'e i!opy ,s'h'Lsreny +w nshed
p, Cer-fled copv is fled with 'He county budding Ir•spechon
depornner-
Daf4/-Q.L_8E:- Applicant
CERTIFICATE OF FXEMPVOIJ F96.q WORKERS'
COMPENSATION INSURANCE
:This section need Fiat be cornplatce ,f the
work �nvolvecl by he
perm I :s for one Ininared dollars ;Sloe; or less ''
I <ert,fy •hot in the porformanre of :he work 'or wnlch this
pernw is issued, I shot! riot employ any person In any manner
so ns to beco,ne subject !a 'he Workers' Cornpensotioa Laws
Dole
NOTICE TO APP,
, J+:, pr'on, you l t ., .. .... .
inensanon pr:..., ,t ... ... .'. a'.' ..,...,.
.,ply w•int suc. . . :;"...••.•.r
revokea
I ICENSED CONTRACTORS DECLARATION"
I hereby r. •! •ions of Chartrr
9 cammr 3 of the BJ -
resS and ;I—: :S ••.'• '�:• •' •: fJll force and
efrr p_r7... .. 22
license N'umre. _—_ 4'7 7. L,c CGnss__CJJ>�,__
..un'raclor Freeinaxi�Date8 20[86 _
I am exempt under Sea -_ _____ —of'hc L A Co
Plumb.ng Cociennd•or Sec __ of -he
B & P Code far he
»__.- Date..-.----._—.._
Signature--- .... --- _
OWNER -BUILDER DECLARATION
hereby a`.f.-I •'•1 .. `•'; m'hF Comractor's 1- censo
w for 'ho . •' 7031.5, Buisness oral Pro
--.ons Cnde'"
_
I. as owner of rhe urapor'y. or my errrpioye•.es wl•h wages as
'heir sole romperso lion, will do 'he work and 'he slruc'ure
.s not tmendca or of<ered far sale ;Sec+Ion 7044, BUsiress
a,,d Professions Code'.
1 ! as ow—r of the property
'¢eased con -roc tors to con+ • ., ,
BUsmCss and Prof'ss,on,. Cone:
CONSTRUCTION i!'.".;"„ •'
I hereby offivn :hot there 's s ,t ogency
forthe performance of the .: '• • .. ,erml' Is
Issued !Sec 4097, C.- C .
I ender', Nome
Lender's Add:
Icor.ty theI I'• opPI ca•ian a•'d s'a'e ;ba' the
above ururT ..''; .. agree to cnmrry whit all Coun'v
Mdmances <• ., ., .. r'.julatinq Plumbing and Sewers.
and herebv ':,. •talon ves of Th s County :c outer
uport'he above-mer'loned pr000r'y !or purooses
S,gnalUr r'n:ttca Dote
Cf 8D9 (REV 8/81, APPLICATION FOR MI'T
@5 ��� SEWER - SEWAGE DISPOSAL `
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
CONNECTION DATA .
AL'^R: Sg
.t=f____—_-Rr%FRENC!
^CR:oi
c,,vFR
--•'E
C3:^.i5 (/�7
C)F:G\\E:'17N :VGI., -RC:•+
.`i ..Y1�$%_—�!__SNi•�
(.:Y3 1• . '7 F I
GRP
NO
OWNER t1891f3:rlY
CO. TMP. NO"/y
7O6'NO ,{Xj
MAIL
ADDRESS 320 Box 3329..
_ ._._
TRUNK PERMIT NO, - ROAD PERMITNO.
11 Covina it. Na 8.18//67-9.41
AFFIDAVIT WAIVER fJ+SEMENT RECORD INSTR. NO DATE
_
DESCRIPTION 4OTNO.Z!j
HWY. OR ST WIDENING
STATE ENCROACHMENT
--'
PERMIT NO.
- DF NCA, ON�.C'y
_p '--
USE OF Sing. O' S.
'
4 iLe a
BUILDINGS ^yY"G!7+�
CHARGES
��'r
. ON�iA;'OR ��I.i��rL�'EErl'RFAal�\,
C'r,Nr.F.?C\::an ROE IFr
n: ,,C,7ONST_,. T..,,
8225 Rea i1.wrmd.._::r . —__._ —
:Lr.•n..45,.vinT=r
)S'R:T NO�C-R:;:.' IA: 'ROCEiiE; 9�
BK PG
. C34-4
"V, 474887 -5,
'
.. NO :
L
17 00 -:.T: 1 U_22
.... OR
OWNER'S I Permit _ 110'AUTHORIZATION TOTAL FEE i/:.r AT t . , ::,+:F A ; :;WRAC- Ani-- EIRE N \a',+IR:I;r . _xE: ND r.li._ING -O'+r. r..S;ONL-) THIS Y'T.IVv1—A7-11;,-
SEE
REVERSE FOR EXPLANATORY LANGUAGE
VALIDATION.
_? Ut6
'10
11-
'U -27,50
-'66
t