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HomeMy WebLinkAbout1514A (8) IWORKERS'COMPENSA710N CECLARRTI"ON ' �� � ' ~ I herehy affam 'iia� I have a [ertrf�.ca•e of consen' !o selF � Insure,or n cw��(icaie of W'orker.s'Compensation Insurance.or '�^"`7' . a«�,���e��o-py��'o�;5e� 3800,Lab C.;,� '�,=���. E�, APPLlCA,TlQN �OR PERMIT PoL<y No�� -�r�'�_Cnmpany._�'t. _ aI1C�"._'_ .s .. .. . � ❑Certdi�Yop'�j.��h�re6y fu�n,shry�i SEWEl2 - SEWAC E DISP'OSAL � Ce���'ied copy is f��ed with�he mwry build:r.r irspec�io� COUNTY OF LOS ANGELES BUILDING AND SAFETY , . ...,.,o.,:w•..an,,..s•�r.:.axW:, ..•. ., wa:�" .Gf,.itina.•., deparimen� .... .,... ... •.., �.".IW: v+::.J Do'� CERTI:ICATE OFIEXFSI�PTION�ROM V✓R�ICERS'� ' �" , I \= FQ'R AP��CA��ILL IN �� CQNNECTION�DAT � $.�2Df$� �' - —---- . .. r .r•�, ,,.. . `--- - COMPEti'..., :'^.,,...''.5\,'- _ " �i_�-. -. .. lF s sec.... .:.;......,..... �,..,, ..,... ... . ... .... .. . _ � �ar..,-�.r.r:r�.�" — • �ki}� �`��G . .�......... ^! .. ./,. �... a' ... �L 'Q . . . � ,.,.....,... . .. . .. ....... ..... irv�x � cernfv �...�...�,;..;.. .„ ..� .,:.ni.� I�_��___ _—.___ .. . iC:;F4 �1P�m�t i5�:'.•:'•� . .. 1�,? . :,1. —___ __ "'— , �.r\G-r.:pp.V � .,�.. � ., _ \I:.:ik�' ��4E�iF CCM1NiC��!>V . . .. ...,. , �• work for wh�ch ehis :r.�ss:.r � . - G ' � . v. :,:•. : •�.re�. pCrrtnl is �.�.,���„�,: '��'�. .. �r.::•„r. r.• nerson�n a�y mnnner -- ".. . .. . �:�3D�.N GI�' _ ,. .`"�. �?„ . ... so as lo i�...:..........���.� .�� �� :..r..�.... ::omocnso•�o�i Laws. :��.n�r; .r, :•:>�.. �}?"- ' ____ . . .. ..... . ....�.. v`� P� BQ}�i �J329 'e�.<�rkv-�o Rono�RMrtnio . '2E•: � Da+e-------ApP��caM----'-- -' —y . . p . ...,..p.....A, .. . . . _ . - NOiICF. TO APPlICANT If, �f:n.r mnking �hi5 �f.r1i{iC0'C Oi ••i�, � S'1V/J�?�JSy�l` A�FIDAVIT� NIAIVEN EP,SEMENT RENRp:IN51R.1V0 �ATE Nl�vinC'Z "i. \.`.: c„mP'�or. You s�.r �a "�..-..... � `�.r.c: !o •he Warkers' ... .. ipr.rschon ��,,...� - .:,..,. — � prov's� , .�:::�.��:�de Yo„mus�rnrth�v�:n cr:,r.u-*c•, o'cc .._ i•.��04;� r..!��c ...nolv w:t� s�ch ��•�:.�:.•, , .. . ;..,�mrt S��l:li t;c dermed _.._ z __ rAvoked eJ:t tvr.:i ..5754.......,,._. �_,�:�-,���:,.��,.,_,- ._ ........._.._..__ _ .,_. .. iICENSFD CONTRACTOR5 bE^_ARATiOF'. •.:c�n.�;s , '_29'°°i. . . .......-.......--,.� ^.N�,^ I herecv aHrr�Inn�I on;I¢ensed untle�p.pvis:ons of C.^.cp':r -:�;F "— — 9�'cummennng wrh Ser•ion 7000`of D�v�s�on 3 0!ihc Ads:- .�?�ne: S111�._Res. :G:S .� :�:; ness nnd Profexsions Code and�ny lirensc�s in hJ:'nrte r.nd -- ----' — � ��� � �� � ��� fi'PLI. CONTRP.C�OR ' }.''y�'�1�j�.�Pi�.� :c�.r.;o�::,.,acr=:t_ . ..,.._... � n ry� i..--- — -- - . Li:enseNumbe..._�I�'B$I.—L� C:rt45_.y�J.�_._—_ AG.:1C.Y.: RriVuLPSF•qn[=E° � _2���eechwood_;�'�..—._ . �i.r��� aa�.,� -ecce.,�__. ,.....,., c�•,«�����_,_�reeman __o���_..���IS� _ : r t'L�.t.a Loma �.: 714 �ad�'fF�2� -s � _ .,, z _L___'.__ 9K�' PG ",�a�n exem naer Sec'__'__ __oi�r,r:L A.Co. '�.=�� . O -- r�'� �:.:�.�:�o c�.� � 7 � —��.��---------�'-s.,r' �= �:. "=SCR P7'CI�JF My;;RK f;t - V PlumbngCcdcnnd�o�5r.c __„_ __.nf�nv __ — � �� �r.a. i .,a r�n,-.-ir.c�c ��,'; OO ;n; VALID ION R . ' 3.8 P Code io•rtir.fo�'cw•eA reason . � � `z `p...2�� -__.,_..._.�....__'_� " """' "_' "._._..._""�.. ....._. F, . •JAL � ___" ' I v - •_ _'a:c..'—_.__—_— _ _ . '_._ .. _ """_"_ '_._ . ' � ._ :. ..� , _.. ,_ ..._ _.,_. ._ . _, Signaiure. . . . _...,... . .., ;. ;r. � . .,_ --------- . ............_ i �a %1 OWNFR BUiLDER DFCLARA7!Oti �� +'�-• ' -• �-�� ----�--• -- :� rj , I hem•^v af�.m .. . ,v rm":e Con'rancr's L¢r.nxe � " .,�.i �..-.r. � . . . Lat�::." . ,:..... .� �..� .,...7D37.S,�3uisnetis nr•d P.o- . .-. . '—'. _ _..:_'._ --' -' - `- -- - f � ;:S W w �s ffi 1 � . . . . , „�.... .., .,,,.., . . ':r_:..: ''-:.-. --''-.;:. .— ._..--�- ---.. .... .. _.._, �....,...... ....r.,...:r.r.. .. ..vemployeeswithwagesas � '"°`^ . . . . -i L�..�i� �•• �, .•�� �,'ron,will do ihe wqrk and,ihe sir�vure _ � ' • �•.. ..:�, �.�fered tor sale(Section 7044,Business ' , �"F a! l.���� • ,:' ' .�,�). OWNER'S Permif ,_. I,os ow�,er of���e orc.po�'y,o+r.exU�isrve:ly cor.trr,rnng wrh AUTHORIZATION 70TAL FEE '�,'� �Q b�:��`�i 6 '�rensr.d rn•itractors'e:ons•vc'•hr,proieC,Secrion 7044, i HqvE 4i l��Cl.-F�.:,;V".A:�'M�1F'�IC'�Ri\�=Vf.'.L'N'2:.;'p:':; R�sir�ess and P�cFessiors Codel coNNea r�-[ne�._r.es^c yrr`ek 5'�N=�;�_ino-o-•.:�����'xv.:a CONSTRUGTION IENpING AGENCY �j �'S , I herccy c!fvr, �aol there is a ronst��alion :e�du^���agency SP3NF:THIS �'� I���"�J°�.2_�V_ fo� thr. � ` N,c wor4 (o� wh¢!i th,s em�.• �s ";�.�kk=� �W✓� L �sxued(5,'.� ..,.r . . :,'I � �..�,asn:;-vC'-�+,.__t_"'.F7�fJAM,. ��ir^" ',.,.,,.:',:� ' '. n�=.tF"s>��' r "� Lendcr's Nome_"'__'__._ .,_,__ ,...,..... � .... .. ..... .. ....... ........ ..........,....,-,..............................._.. .... . ,... . � .. .,...,...." " " . . ._ . :crde-'s Adcvcss___ .�.�� ....,.._....�.. ......��. � ce�•�fy ••in• I nnve •enci �F:s anph<alion ond s�r.�<: �hna;hc cbo�c��forr�:r�an�s ro�rcu.�a�rec�o cnmply w;�n o'�Co�^�.ty ordi�:nncr,s ond Stai� laws�eguin!:ng �lurnbi�•q a-id Sewers o�ci !:ereoy ou�honi=reo�nsema;�ves of d-ia Co�nlp ro e•i�er �po��he�b;�v�-me•��•�oned��rnne��y fnr i��spect�or.purnoses. `��_ . . � �u.vvt a�.— ��'��—�"S- ... . .... .. , . . . . S�gno'urc �?crrr�c<: Jn4 SEE REVERSE FOR EXPLANATORY LANGUAGE' . ..,.. ...,,,��... . ,r, ., ..:,..�.. ..:...........:.,..,� ... . . ,., .. ,�....� ., . .....,.. '.r , �......�.,........,..,...---..�...'.........-.�.«...........,....:;�m+.�.�.�.....,........�,......�....,..��....�+.�. it3�PECBe3R's NOi�,._.._..�_.._...._ ,rJ�1,�TFTc-�FJI[.�E.� �:FC:a.AI2 R'I"6�f1\ .., �'�'RfJYl6,r.S�...�._. asre'.�.,.'.;:,...,,R_,...x . ; . ..'---.... ', .. WSPCR�RSSIGNATUR� , ._�"__'.. _.. .. .�..'__.. ...""_' ' �TI101'fCDjz9.Cfi�Ti�'e.`�.�•:iYsuf.�::LYOYriY�IC:�ratrac:'ru's A —_� .._ ,,. ��—....,— A.— � . .. . L.'cense:.aw:or.�e£cLawirig mea;:�,ISas;s.n l0ii..`. , r.'; � ��... .. .._ . _..� - �uslness ssed Prof�assio�s CodeJr Any�efey wr cou.aty CC�,:•'n . ' . .... . . . t :�. ,.�:�cw�.::re � �- -� . , . . . - � aohrc CQPdYf&8 6�6AYKX€oo cotue�wci aites;smprose, -_.._,:..--------.._..._ ..,..--'---._...---_.. br w .:ir�n.< ��.� �-�---•-- f '— . . . .. . .. _ . _._ . �emolaa/s,��oz repccr cny scrfeertss:�,'pwe�'2�z�ts isarsamc�e, nV`':V::kn w:'i� ` I .._ P ' -� . .. ... . �. i ndsc vaqa<rra: thY ay .«.;t;o-a:�:.> er»at2 so jik a __,__'"__ .._... ..,.... ._.. __ i��{:1[ar!:Il...!1n�1�:'; &h3''fl3 w: fSCc':inii 1}'SNMRk RC $dE CEiSPUOt i) OCYWEil❑ . .. . . . ..... .............z . - „ "' � , . . . , .� . . M....::1,'�i.'-:.Y l� � � :�::a �r,.:u�.»:nr'. '.nrsaso i,;.;r'C.3onesr 9 a:hz REPAIk.SCWEQ OR .• .. ... . /yyqH:J.O:�.C.<:o �.;�.ivctJou '30�J c�ls�+:c-,c�o�`tbe sewnce oiscos,u svsren! - $uriness.wrd¢rore:raion:: i:o��°a- mF.�s 's¢ Ss rxc:va t �: � A �i:� .. �. ,, . � , . ., .... .. , ... ..�....., zherefrom uwa.�ie e.ts. , � �i�� r �.'"•.;, – '-- -'- '--' . eac ��sev ic rnvss❑ . . . .'' .._ " •., ..•""' :i,n h � r �r i ,,� .�.�x. SEEP.Nt>) .��..��W':..G :,�..��.–�.�..�.. ... ---'— - —' -�� �_._. b : _. F..,. , i,� ,�.���„i.. :um�: . . . �i. . ..,, . i:r1:�::, .,��d,:1.r.F,::�' ;:;,•. ,j., �. �. � Cil,a:��. ,..:�:�.'r.c;,:op�r¢ywilido¢bewa,t�,and . , � . . , ... ::.;�:,�c— khe atru.-tum in,«r4 i:r:;::u3cci cr ofts..d fos sale. __.___. ._ .�_ �_ /Sea 7044�:�r.ai:�as sr•a Prcl'e.rsSo�-Codei 7T"`^�mr . . -- . � trxaors Liee�ass�aw doas nut un�,T;:ao aa o� �` .�..__.._..�. "� _. --- brnparty mFw i:si/dr r.r;:¢roves:ue>s�r:,amd uBo'does . �.'—..' s�usb u�n:F h3mseCf yrr�ided tbad stesb aseaprovem�nts • •---` cno rsas r::d.r.da:��•,yfo�rea for sale.IJ;bowever. tbe � , � jJi61GI{A�' Gl DiieprOVL'i.iki.L 'l.{i"�ii;A rJYE}�AS] ��Ke�BpY _ d� ' . . _ .:or.tp7eeiot�. „Ea' nu,*a�nbai!dsr rusfi oave tye burdes ... .. . ...,� . . .. , ..,uf i9y'ai'vinb:h�x.;r.c :�.�7 vni ��k{Si�.:.T;9:.'j>Y'�LF fw'3bs --• '---------�_.. �Ywpose r,*ful�.} __---- --- ., , ,- .__.._-'---'-- •.-_ .��n1 eRenlpY m�d�s°�eC. � ___..._.._.W> _ �3 Bz�.�.£c�r.�s's reasox�---,.--------.._..__, �. -----�— ------- ., -- Da?e.__. .��---._.e.._._ .. � . . ,�_--- • �— C?wr,i� ---------- --- ... ... , .,.... ... .. ... .., . ��._-lNSAwC76R'S Pf07ES � � . ' -" . . . . - � .. . . .., . . � _. — _..—�..--'--'---- — ------�'--- --- --- .. , ..�. .. .... .. .... . .... ... ..... ............. � . ...�_iv:.-�" . .. . - .- .. , . , -. . c Y.... .,w..�� fwih-i.>y;.ct:��.�r..�'w:YJ.R.h.-.iw%�f.... .. .