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HomeMy WebLinkAbout1523A ____ _ _ __ _ _ _ .... I . __ _ _ __ _ .. ...,_. . . . - ... . .. .... . . .. .... .. .. .. _ WORKERS'COMPENSATION DfCLARATION���� � P�i�y h��__ • `f. . .�ndircte of consenr ro self � i�surr or<'a.::•..;;�..,,:' :.�.•.�,�t'Compensa!�on insurnnrc O• J6Aba1D . . .. . n cer.f�ed .,,. ,..� �r.: :ii'.'9 � h C.' ;c.�.a .�, e 4� �...�:.. ,,.. ,., , .. .... ��cmPmw s�._.�a _._.. ... „, �4PPLlCATION�FOR PERM�iT �... � '�- �7,�,���',Y��,�:,h�d. SEWER - SEWAG�E DISPOSAL � G:rrd�e t � s.i • ._. .�. .,,... , ., .. ,. .. . . �Cer'i?ied cony is fnen•mith�he rou�ry buiidm9 mspec'ion ILDING A�ID SAFETY ,„p, ��,a, ., COUNTY OF LOS ANGElES BU .,..:.,....Mo... ,.�rr�-, .,:,, ..i .,��,s...-P.1"m,"•-e' r�' swu�wxk 5�'aKrt�' ...., ., deocrtmen• •• � � �o�e_._8_20 1_8G�. ,;��on,._, 2°2em�,E1 .____ FOR APPLlCANT T8 FILL EN CONNECTION DATA ---,: .. ..�,...:_.... _..__.,� --- . �R71FIC�MP[NSATIO.NI INSURHNCEORKERS' _,i..i;��, ... ... .. ._ �f ."' _ . . . . .,:� .,��,��:�.5 ,�YL',�3��..���s ,��.�.�L , . ,.� _ �Thre aeoion need no bc coinn���eo d�he work invnived 6y the 7�T� 'pn D �,=npF . L I�� ":)��:'Y_'_11J..fL.iltlCl___�_—_ "J.c�N;:_4NfYPfN„ oermil.s or o.^.e indretl dol!o�x iS100`o�less'. —. _ .�. _�tv±4 , �, � ' hFa4r:� � _- _=varC�^C�+NCC'�.^.,y . •• .I�C1��rR0`l <c�t•ty � or v,. t+c Fe�formon:e oS rf:e work fnr wn:c� 11•is ,k�;5;y'_��',F ��1'� pe.�m�r is�ss�en, !sndl^of i•mpiny a�y perscn ui any monner •_� --^—`—�--- -- - "``� ���-�'� "'•=��--- so as ro be<cme>ub�c,�:o ihe Wnr4cr5'Comoensaaon LawS. omnF, ���� C.�j _'�o .r�:�;: ..�d��-f� •ry , .,. __ o����------"',.,,:.. ... . . -- --..._ .__. _ .,�.. PO BOX -.�:�<�W�-•.� �:.��Fra.,•.,; �:,-F.,> —3�2�--- . _..,,. NOTICE 70 APPLICAN'. �.: .^..,. ..��.,.�. .. ,; ^�,.... ..,, �.. �� f1� 87.8 � � -:r�;;..,� 7',r.e�a r.+yr�.,r�.' arcr,ec m=Tx�r. ;;.r . ,; . . . , �TA _ ,�.a�rnnhnn ynu sho„Id nerome s�c�ect 'o �Fe Workcrs' �--- � � - 1136 N:7 � :�](?�IS(Y'i7f�?�OV�S�O•`5 Of Ih0 lobor rode,you R1J51 i011hW�IV• ':�:•. , _ .. ... . _ . ._......�.... :;15(2�'C� -J�'�;' �� � 1;."::R�'WIDENIIJG�� ..�npiy witl�, su<h urovis•ons cr Inis permit snal� bc dnemea 357 � � _ �evo4ea. =C:< 't:.:' __��.__ ti'.•rL\:2JACHly\ENT:-..�.: . . , � ••• � I.�CFNSED CONiRACTORS D'ECIARATl07�1"'� � � '`�• '�`r=�s �°�-- - - - - t:7t�' o• . . �C::C\.^i :hereby o`4rrm�hc•� �_. •.. • ••.P,ov•�,ons o°Chapir.: a�� . _ . . .- � •. • Sing Re� . .... ,...,..,�. � 9 iwr^mcrung with )wisior 3 of•ne 8,�s�- "�.�__iy;;; , :r�:.cC-c ,,,,...,,.`..,..w...,. n�ss ai�d Proress•o�+s Codc and�xi�L<ense�s�•i iu6?o•ce and �_—_— ---- �� ����•-�� �__- effa.r :^�•.,C'rt FREEI�'1�N CONS 2• �,�'�F":1�;�n:r;r r,-t . . �. ,..,:...�. .�...�..,.+w_�r.�a��:. Y ���o�:otv.�,,,n�• -4`T4S8'7 i,< c�a.s---G34 ...-��•,,, � :r:,,i,.a=•v�n._, .,., a 8225_.Fi€�.S�idnos_�r,� --.--- - .� � ......,.. � o c�.,,,a�:,�-_�re��an----u�r�_�/2.4Ls'3�-- _Alta I,oma^�•,_q�4.L-98�.4�29 f.°'kl�\O ::Ri)JP ../.� :YO[[gcu:SY V � ry� x � c.0 PG L ' _ 'nm exem,pt unoc�Se:____ cl tFa L.A Co `ic[us=n^�!.t8� :.�.�5•_Ce�[�- �� II I Q �:: D;S.a.,'�O�OF:9oeR --1—�—_ [- Pl��mhingCodeanr:.or5r.c.___'_'_ `cf�f�c - — � g, .. '.)l.:'ifrr."�^.�Vr^:\G T:. . .. :.-_' W 8.&P Code for rhe iol�io�vinq reasor_. . ,_�;`�•'.`` .. I_171_QQ_ -..� (Q-Z'+`g� �VALID ION _-�„_„, d .^,f:.'��C.�..�:,^,�:•�� � .'r � ' i .•c nNi...G f..l.\-�.'; ... T�:I.:�:iF:.iR::•N�::^-;,r,•_ _'_ P�� � :.�:,. �. ., Daie, {----� n.. ,.•. a�•r.�=�.�s:.i.,,�-F.� � i —_.�-l� Signa•ure-----.._ ��..�._....��..........^�..�e.,:>.:�.�:�n� ::n.�;��.�,x: c�a s.:;<:u --r'--� — CWNER-BUILDER Df.CiF,RATiON o.:iai'��a.�cF c.;,.e � (� _':FF�IG;'.4k'>eGF�li "'nA^.F:l:: �_ 1;� .�'.��.�i YS I herr.bv afi•rm•hu��am r,xr.mp��.oM•na Convra:�c�'x u�..rsc 'x�•, c.ss:.�o- �c�nEi� en•..-;;_[ - a'o•'k•eioi,owir.g:��so��;Sec;.n7031.5.B�isnossondPro- -'� ?.iiicr",a;zn,:.��oa:iei.s_ ---�— �'^'�-.ior.s Codei �.::a:�i;io=r.s., ��sr:v I °;e � c o '� I� _ . as owne•o+�ne property,or my employees w�th wages as - t*= �2 7 u;;1 :tir.r solc conpensa•un:,will do the work and the strvcture � is no�i••icrded u•offered for sale(Section 7044,Business " ---� � ,_, ��_.�r�.r�� . r.n;,aro;ass�ons Ccco: iZNlNER'S Permif ,�I-�Q ' � � � i ' ns owrie�o+!he orn,r.�i�y,am ezc;d,:vely coNrr,<t:rg w��;i AU�HQ�I'YA�1(O�„� '{QTA�FEE� �v,C�"Q�J licr.�s�d rorttr�c:ors ro rors�•.,c':ne Pro�rr�;Sec��on 7Cm. i Hnve.aT*w5 on*E;,r:;nraa:'':,if•.,:i�a[�.w:�['+Cr•r:a: �.. � duairessondP�ofesaior.sCode- coNNer.riHensoOect,^:7=nrxs-�:;:�J.!_n0•.;;;r.�i-_:cv:.0 � . CONS?RUCTiON:END:NG AGEIVCY p - 6� , i F;o•c•;;y nf��.m d;�y •.�ern �s n rnr.s�ruUion lending agency SIGNEDTHIS DAYDF d� 19a� ior Ihe vr.�forma�re o% ihe work for which +his permit is nwNFapa ��� (it�e/'i :rmra,..n.n -�' s1.d.i[Z'?�..' �swed�Sr<.3C97.C:�v C� • --- —" � c:a:fl�yy '.' ' ° , ' n Le-de%s Nome• -�—' � �_. . ___—_.........-..�....,..,_s.,_*.,n,. ..: „ .-' �:'. ic•�dcr's Address . _,o„ . .. ' - . � � � . . . � � . � � I rerriiy thot I�hnve read(his applicahon and sfafe ifiat tbe � ahooc inicr;r;ot�cr�is torrecL I agree b comply wiih all County o�;iinances and$rn'e lows rcgi,lo"�y Pi�,imb�^c mid Sewers. or:d .'^.en;ny nut4orve ropresen'a��ves uf:�•s Co.iNy�o enta ,�por"nP nb�vr.mPr.���ner!c�rooci�y�o� ���sner��o:,n.,rposr.s _o--.lC^Mpe�'-�;�,•,,r�_G---.--.�'—c�� �S Sicr:;�ure o,.errn.!•ee :�'i± SEE RiVERSE FOR E%PiANATORV LANGUAGE � ,..._.�...._.._.......isaaP�aR'SNO7E3 .._.._� .�,._ ���!�4FTd.�Lr`IY.�Y�.!#lJ�G:.la�!'i:'.��.}.'�: ....._:,..�.:...q.,�,..at.4::,-�.��---„".'� .' , ._..__=.___�.=�. .: ��`�.,..-.e...�: , . , A,QPROVs4f.S _._ ! nn� iE � INSFxGTOR'S S�GNATURE �„rriL;ixiir.�.::h�..i t.:�n¢..�:�,>.t.ue:,x'r.�..•'o�:aeacxnr`n -------- ----—-—�._«_.... ., NEW HCliS'YWER � �� [:'s.�n:w L•r_w-fo:�.:ye'?aiicf�ing re:;�ur.jar::t'�r..a v3Y.5, ,\.r--:' ._-•:n —�— .. 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