Loading...
HomeMy WebLinkAbout1520A (8) � - _ _-_. __ , WORKERS'COMPEN54T!ON DEC.ARATION . ..� ...", ... .--+�' . . -�._ .• .. . , ` . . ... .. .. ... ... . -...-.. � hereby offirm Ibo! � F�ave o cerhi cute oF conse�v to self ... . . , � .. . .. �..� � ���� �'' . . � � nsur= o•a cer t m•e of Workcrs'Cornoersa7:an Insura�<�,or '=�`��� � " .. . .� � '� ��' �<e•,{�ed copy tnereo!(Sec 3800 ���C CE806'Fi. a�: qpp�}CAT�ON I�OR F�ERl1AiT Pol cy,2n+q.��y�_ Company---�t..-�"��-- — `JPs =ce.�'7��"1T.�reby��mishea SEWER - SEWAGE DI$PO�AL �xCe�•�fie.d<opy is 1 ed wi�n���e counry buddi•�n �spectio�� WUNTY OF lOS ANGELES �BUILDINC XNb S/�FETY a,:..,_... .:.. .. ...,... ...... . , • :.,. . CP yImEn• "_ ... . � . . . ..u......... oo•o�/2QI�6.Apo��ca�,�.._�''����a'??__-__� FOR APPLICANT TO FIIL IN CONNECTION DA7A � CFRiIF!CAiF�OF FXEAAPTiON'�F'ROiGS�WOt2R�hc5' � z,i �•N;, J16f.�y,�� �J,Z f 1���I �ra�Cn _~ :xP'�+ COMPENSAi!ON INSURANCF� ;:>>u:�s �J � ,�� (.._ _"_ •,-.-- - —_ jThis seriion r.eed nat be comple�ed ii•hr.work involved bv!^e .....,� .y t�} �p.p !•:.\-I.^.I Hi°hkCNC: ��,�_ perin:+:s�cr one�•iindred OO�if](S IS����Of IC55�'. .•• —�--.�+s+—.�n��—_ /�.____�__...�__ -YPC�I=CC\M1F�:in ���.F�til �JJ-b�_l.e..�— 1'Nu:rl.n(Yf. I ce�t•fy ��iot :n ttie oe�forman:e oF rhe work for which ihis ;.;o:,��.;;� �,{i'� r_ u:,� �'�-��,-. . . pprp�,i''S issucd I shal'no+ert•,p:oy any pc�son in rn•y manne� �' r r �.-; Gr1 so as!o be<on�e su't.��r.c�'c the Workers'Comacr.soncn:ox�s. ca��rc A,.�;DEN GRr _ �;�,F�:� ::F•.�: �o Y6� ' •:�cll �O �Oh ��2�j "t.�<Fk�'.•.'1C ROt��CF\•:'�. � n"I:�il>_ Do'c___'..Applicon'_'— —._—___ — —'_ , Fi,nr' .�:._� F4iC':��' R�CCFC I�cTF�:: '+•'�T= N0710E Tp APPIICANT �F, o4cr moiing •his Ccr:ficate of COVjra, - ^::�81��6' � �v :! r6xrmp'�on yo� stiuuld becomc s•ariec 'o thr Workeri -�A: " . � ^.p2�5O'i0i1 ornvis�ona o�'he�obo•cone you�h�'si io•;hw�ih pESCRIPiION lOTNO NWY OR ST WIDENING � � .,npiy w�rh s:,o• prooisien9 r,r •F.,x oermu +hall 6e oeemed 35754 --` �E!�Cked G.:),:< �kTCr '_3�'IT\C)�4;-I:'�:Y� i ICFNSEO C0�ITRACiORS�DECLARf1TiON ' •�°�°�-.'"y ------ _ s 1:c�.� .�+.3N.c; i hrreby affirm i�u:•�i om��censed.�ndPr oronsions oi Choofer USE OF 9 ;;o�nmr.nr.i�q w41� $eno��7D00' or J�vis�cr 3 0(•he B�s� swtoiNGS �HARGES ness and Pro�essions�ode.nnd r•y:•.crse�s'�n+;d '*orce a•id _„ ..� . .._ _.....- .,...... . .....____.._._..__._..__....___.__.___ Cfft'Ct �7 n CONTRACTOR � CONNECTION CHATf'GE FEf"���"� �. ..... _..�...._ _.., � !i:e^scN,i�r.ber_Q��T4SS1____;�� i.1055._.. �!��.._-- :•::.:F'-.ic BGGr Beechwcod �s �:']�.nSk::E\'F�� ' V ��'']CLPi�lAT7 __�a•e_._ :i .l��..t� ZO1Lc1 ,i•.:; ��:s.c:��.^ �z::.:. ., =�cctss:c3r co„��a���� H/2�Sb---.— .714L98Q-4_4.2 BK � o ,-,,-:— « . �I� I._ 'on:exemFt���da•$er__--.—_oft�^e-.A.Co �Cr�:;Etic `�4 _l4 L� � u � —.,__—' _' �'_� �iSCR�'InY 7F�^i:J3K _rF` _ r�:� ' .'�'.�. W P!�mbinG Code end�cr Sec._ ______ __of thr, - . � �i.�,s.r:,c�cc�nr-�o-c � -i.� � -�-r `�_.L�` / VALIDATION_.,,._.._, y 9 8� Codr.ior na followi��renson_._'___ , .t'."�'•-� , :.:__.. �-... ��^ " ' __' _—..._..__ ._ . .._...__..—.. . .. _ . . ' .. . .' ._..:.' ""'�''.�..._ '_"' ""'_.... ... .. -. " ! __ —_Dotc"____ _ i . . . . �^ . . ,..:,,:� '__.._' '::__ : _ .. _.... .._" . . ..'""_ . _ - Signa�urc.—'_—'_.__._ . .. . �,•. .' '... .�.'. . . • . . .. :. . . . ..... ...: ..1_ ' OWNF.R�BUvDE2 DECLARA?IOV . . . .._.., '.._...... "•"'_ _-.... _..""".� . .._.. �.... � O E �hereby o?irm'ha;!nm exemp!i:cm:f•e("��.. .,;.....� , ;,,..�i. , '•. '.. .. ,• :: : .,. .._..._.....— ' "_ • ... -' I , . : :.: ^ _ .� __. � .�.. .._, :_... Law ior'he Fr,liowin,renso��Sectori 703L@. t° � .. .. ,.- ; " • , ' ' .H�+. � � I U ' .,:..,.�ors Cade} ��.,, .... . ..,. .� �'" .i.". .__�.. ..... ..... ..__' " . I,os own^•or d�a Property,or my em.;��oyecs�.vrh wnges as � I a�o)�,�� 'her,solc cr.mpensohor.,will do:nc wurk ai�a'r.e sirur'ure �s not�rrended o�oife�od for sole;Seran�70na.B�sinese �.:�e�'�,{}{�� r.nd ProFess,or.s Codr-� QWNER`$ Permit i� Zl7 �J� � _ :.as nwrr.r ef�nc a�opc��y,nm ex-h:s�vciy<on�rac•ing wrth AUTHORIZATION TOTAL PEE , F� t�`[�.��7"'`�G`fl �:censed rnn'roclors ro cons��,:ct��^o proie:•!Sr.rlion 70nn I HAVE AT'- ::i[t„�7a•"u•� '.F•if+^Ein nna�;^,��'v�.:ce rc 8us��essandP�O'C55i0^s�OdE: CONNECT ^i=9C�F':`YRB"1.x�r•�c:r.: �i_•-rir�u6.rstn�a ' � CONSiRUCTICN LEN7ING AGEfv'CY �/' I hcrnby affr-� •Fin� �m+re is r. <o^c•ruuicr Ir.ndinq nqr.ncy SiG�CDThi:i��J4YQ- -+� .�4� , for ;i,e periormnnrr, r.f �he vvnrk fo� which �his pe�mJ is ^:`:�E:::k ✓ ��- _ �...�:.p.,:.:.�•�L�--� ISSUE:I iSEC 3OqI,CIV C�I n,�;c: -�6�-- �� � � ' � Lendm's Nnme_"_—_'.,__'_".— �__- . ,. , . . . ' . . . .. ... . , . . . . ... ... . .. .. -. Lendw's Acidress_____.—_. � � � � � -� " '�� ,.... . .. .... .... . . .... � . , ��.rhfy �hn+ .' tirnr. •eaa �n�s npphconon c^ti s7c!e 'i��!nc� � abovc�nfo•manon�s oo�re« I cg.r.c�v comp�y wdr o'!Co�.nq� � . . � orci�•.encrs n^d S�rna Icws r�gWai'�ng Plurnbinq ana Sewers, , . �� ard nerecy au�harae renrese^�ohvr.s cd'his Cour:v to ericr upon rhe auove men'iore�i p•op;�.ny icr v:sac;�wn p.I:DU5C5 �,���� _ .�-2-s-Sr� S:��nor�,ic o�Pc�miltee Jarc SEE REVERSE FOR EXPLANA70RV L'ANGIAGE � �...._.�._._,_�s¢aS�EtiosYSa�osEs�.�.._�....._�._ `���R••�*JftI.£SER F��C�.E413A'TIQPd , .....m...�r_...t.....,._.,.�..,.....,.n.,.....��-..-...,....,.,.5 . . . .. . .,,., . H���'�.�1��..y �—OATi �� :NSP[RCR'S'.IGNATUR? ' ___._......�......_..�'.._'_'____"___""__'_"___'"'" !ti`".C17':ul:l�:. . .. ...��� ....~.ylll..:c�,�� .: . �-'-'-------� �-'----` �.:7C�La..,(..Prr�n,.+s3u:ec, .'� '�.. . .., ; _..�.... ,d ^ ----�--'-`--�—�- '---- --'--"_--------- .i, sa .^.a5a ;�.aa: 7.. , .. ... _ ' :�i � '.� • 7@$8CY01'8 __"._. , .. ,-- _�n...� . .... . �,V �,,; �.(:o.-r:n:�7031.5. Ni\v HCVSE GEWER i •/:,•✓ ..-i:� . �''��' ,C_.,1:. ^ : � _x...._'_."__..--.—._ _: . 'f+ Cl 09'MkAd�}' CANNEC.r qCD�T,CUAI ; ! .d � yjp � _._.....___"'_""__ ^L'II.DIN.CR WOP% � 1 Y � b�7J'C^ "NQ b'1'r A:9':::Y LL t09b>$Y1iCf��R��89➢Ly�JTfW6� _"_._a_"____�i._'_�_��_�.g .� �.„d n;dP:IC TAkK.SCEP.WT(5! i I 9 —•�----".'"-----"'—___'___'___'_.'_ . . 70�,SUr nT:"d!2'p'.[A;Y Yih:C>CB8f8r S�`�6�7Rk 1SSN(df{CBs $AYp.'OR DRA:Yi�IELC ! T__� 9r tY,VfFI#iYi,i wil!. MXi=sAn:J(r9 .:<st�y{}g;yPyyy§p g3Y�k '� �`"���`—�` �y . _ _� si�resd s;aCerr.eat thct�e as :sr,a...i��=p7x¢csucssi ta E�e ('c55FOC' I�__.JR'rY/E_V 4__'—I_—._—,.—_ . . • .•.•�•. .. • ... ..,._.. . . .. ..�•pTOtMtTOl85 af tha Z.�095�'6CA'SF'',:I.SGC91..'f.�YG9:,t�i�fYtBY'.4 �c���.o�uisaosn:srs::n{ I —'-�-_- � -`------- . .�. '- � ..` ,. _,,.__ . . SuaAmeas�p�7'rofeasAtesae C��as't$md�e•, t&e :LL7Ek,RE?A!R,i�WER 00. _ p' _ a +_ _ � ,;�::.�•fr••3 a irsceNncT��wrallo � _.... � . �--'----------'----------'---._�......--•---------'-•- �.,/m�„. .,ti,....,.:fl3i.5:,, .nr:;.�t � . ----,_�.__..� ss ex ... ", '., Eed rz..esnptioa.Any ...:,._ ....�..�,,., � � .....: .S500d•; �tte . _.... BACKFI::SP51ClANKS.�wss-Mv:,:..1 i.........a� + , -- P LNd�:� ....:Sd 4 GY:.:�,.�..�r;>�.:•.. .. ,',.^':�.Tt' HI1AiJ'JON N(1USs SE\VI:N u d� �' SEEI',AITI51�l CESSPODLS L.I � 'IFii.:: .J•::f� ��n;.�i.�'?,�.i�I':''` 'w�:� �-- ._.__._� I�Y,as;he ows7e�af eh�aropeety witE des eds.we.ik.ann . . . . � . 4�tC SY[HC4lF%C 4S Yl�:1i28c'A4@5(!E'OrtfEii'w:Gi 9B!:-. �_.�_,_.—..'.�- - �� !S¢u 7�4$.�usd-x:s:tam�Paujess>.:.s::�s: �:. .•'vw � � , . . • ' ' 1tY6[tiUi'8;:..c,:rssz Y,aru does n+rY qpply b��oi �of _.�_�.__.`.__.... _.,` pv�scrt;�:::bc brisTds ar aaiapravas 2herc�,asw'w�o does . .-. . sserlr .a,:,�•.:�nd:,:::eY}�rroueded Pbas sacds smuprovesnenRs ' —. ----- .--- a s not i:asv:::tsaa ar o,�es�j'ar sale.df,bammarer,tbe . ' hi(88dtag nr ssnap5a�o2i3merat ds so&t svithin,one year oJ ._...�--------.__,_._. .--- -..__ rorxplc�[e�.:r. L&e osv�e�bs�6lder.will ba-ve 'the burrlen . . . '." . .. �f prca:rxg�lia¢6rr,�.�d:;at b:::ad..r ;n:j�vov3 Jc:�t�is ---;--'- - ------..___._...__.__...---' purpose o{s.sYr.; , - t� . . . ,.. .. . ,, .. . . A .. , . ..• �'�--'--^----'--�-"--.—._.._..._.,.._...��_,.__._,_..__.. ' ��Tl ""X�'x:3:'iYi ilYt{l'iC.Y' _ ......,.....__. .. t.. , . . ., . �,. . , �.. .. .. ..... ,.... ...�......_.. ,_.. . _..,�.:...._.. . . ,. . , .i, . . . ' . '___'__'___- ._ ��?�',0....fuY.Y!1S ie:iLtiYiYi'__"'._'�,_.- � ,.� . -'.�'� . ,— . _"' �3t2�._ . . . � � � � --- --'-'--„-- --' . . � . . . . . , .., . . laF+vh�".--'—"-'-------'--._._._... _ _'_- '_ - ..��..�._._....-..........._._�._.._,-....___.._...-.,........,...,._ , � ,. , �r�� . .,� , . iRi5F1ELTSSRS¢SOTE$ . .»,r-y..__-..,-.-,..�...._..,. .,�,..�-�.�u. .,,;.,,.��:,c .r.:�:e..; ..,.-.-. , . . . - � . ,..M=,.�._... ,.,�. .., - _ , . . ,K.. , .. . . � ..r ,r.�<.,.. . <.,..«P,..z �.<-:,., w2 x=,� , . . f . . ..„�.�.„ ., ..„ . . ,. ... .. . ,,,. . .� . ..> � . .. � •-�-- � . .. ,� , . . . _ � .._�. -' -------' --- .,. . ...,,....ti,..»...,.��............H�f......a.�.,.,�....,,r,.............................�,,......:.;.,. . .,.....�u,.:.��,..._,. ...y,....,� ,,.:.,.,..,.'.:....::. ---- — --- —'-- -- -'---_—'^-� . , .. ,.� . . _..,... , , .. . ,. ....�.., d,-�. '. . . ..�:•, .. � ..: t.:..�., ,�... , , . ., � _"'__" ' _ '-, . �_ � _'� , .... .�. _.r r.n«- � . . . . :..i... � ..� ,;... . ... . . ,.. �._'_".___"'_' _—__"—____""_ _"--',_' __�___' ��_, . .. .� ....... . ................,,..,r...�,�, ...�....,:,�,.., .....,�...M.y:.,�,,; ,.,,. . .. . . . . .� .�«,. . �../.�.. .. _.... .r.�..�+:.e.^i.:N..,ys,.s erv