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HomeMy WebLinkAbout0809A � �---� --------- __-- .__.....- --- ._... ___ _.�.. . -_- __.._�_. ___. _ — .._.__. ._..._.. .---------- - . _.. � I WORKERS'COMPENSATION DKIARATION � �_ . ' � .... I hereby offirm ihot I hove a ca'titimro of conaenl ro self . ' . I , � insure,or a ce�tifi<o�e of Workori Compensotion lnsurance,or � ���� ! � o mrtified copy thereof(Set.3800,lab C.) �E�,°��.e,e" - ppp1.ICATION FOR P�ERMIT � � � -. Policy No. Company mi . . ; ❑ce.,;,;�a�o�;�,,e„�,�,,,;,h�a. SEWER • SEWAGE DISP05AL � �Ce.t�iied copy is fHed wilh the counry buildi�p inepeaion COUNTY OF LOS ANGELES BUILOING AND SAFETY deportmero. , ome F+ppliconr FOR APPLICANT TO FILL IN tONNECTION OATA � , CERTIFICATE OF EXEMF710N FROM WORKERY � �i�oi� .T . COMDENSATION tNSURANCE �oo�s z.��i/� �' � �i r[.� st.+raN oeprH . . � �, (This section need not be complered if the work Involved by�he i�i�TM ... �p0�V.f.� //y1qHpE REFEI3NCE . UfVER . � permil is far one hu�dred dollara(5100)or less.)� - ' R I tertify that in ihe performonce of fhe work for which �his ���p�5555T, ' T�a���� . ��+[''TMFap+' Y. - CURO P.L M.LTO►.L ' } ' permit is iuoad,I sholl not employ any penon in any mannar y. so ae lo bemme sub"ect to the Wwkers'Com ensa�ion Laws. ' � � P'���� O . 1 P oWNFR / [o.Vnr.No. Joe No. V . AD 101fE55 � . ' iRUNN iFAMIT NO. .. . ROAD 14RM1T�10. � Dote � Applicant , NOTICE TO APPLICANT: If, oher mekin �this CElflfit0lD Of . �� � AFFIDAVIT , WAIVEY [ASEAAENT RKORD.iNSfi,NO. DATE Q 9 atr tei.No. � F- EKempfion, you shoold become subject to the Workeri . i��� � - W Compenmtion provisions o(Ihe Labor code,you muat forthwith pexk�vr�or� ioiNo. � - - ' q�vy,pttsi.wioENuaG . � n. , comply with s�ch p�orision�or this permit shall be daemed . �A rOvokeE. BIOCK � iR.KT $TATE ENCROACHMENT G LICENSED CONTRACTORS DECLARATION "°.o�u°�s. � r�°Mrt N°' I � . size ov ior � roow oN ioT � - I I haraby affirm that I am iicensed under provisions of Chapler � � � � `! 9(commencing with Seuion 7000)of Division 3 of the Busi- Bwio�s � � �H,�xc�s B ness and Vrofassions Code;and my license is in full forca and �y + ef{ett.� . CONTRACiOP nf�a/�v CONNERION CHARGE ffF . � �iCBnSe NVmd�f - LiC.Class � A�E.� ,�3 '� � � YEIMlURYMEMT FFE � Controttor DOte ' Y DISTRICT NO. G¢WP� MAP PRp�E55E0 BY arr C� 7E�.rao. C f y�` e� ac i ❑I am exempt under$ec. of the L.A.Co. iiCeras¢r+o. JJ I V nAss� -�� �Q • �� ���� No. � DESCRIVIION OF WORK iEE Plumbing Code and/or 5ec. of the HNq� VAUDATION I/DUSf SEWfN CONNKi1NG TO . D�iE i� ?/v,/ ' � B.8 P.Code for ihe following reason � �BOC�p ✓ o'� t Sftt1C TAN[.SEEPAGE%T OR � PiTS ANO/OR ORAINf1ElD ' fINAI' ' ' DOfe . �$[gyy[R CON�[�CTIIYG TO . BV � Signoture �°wo°t'�ro"i+a se�"sc ER°�°R � $�8 Q 9 A , OWNER-BUIIDER DECLARATION p�R ypyAC�qT,DRNNfIFID � . � � ��.�a ��� '� I heroby offirm that I am e.empt from the Connaetor's License E%TH.,C155POOl DRYW[��ruw'qie � � � low for the following reoson(Setlon 7031.5,Buisness and Pro- � ��q�oa�5��nwsE . , �,•,'2�,rJ O � fessiona Code): . . . . . . . . . . ❑I,as owner of Ihe property,or my employees wilh wagas os . . . • � �2�,Jr' Q� , their sole compenw�ion,wili do the work o�ihe sKUUure � � � is no�intended or offered for sole(Sadion 7044,Bwinecs - . � O��O 3�a�1 - aod Profesaions Code�. OWNER'S Permit t .S ❑I,as owner ot the property,am axdusi�eiy controciing with A�HORIZATION TOTAL FEE ' � ' Iicensed comrocbrs to tonstr�ct the Pf01�«(�«������ I HAVE AT THIS DATE A CON`PACT WI7N TNE NEYEIN NNAED CONTRACTOR TO , ' Businesa and Professions Code). cor��cr rH[neo�oescp�eFo exisnr.�o�+rtu�Ne ro n+e rueuc sev+ev. - - - - � - � • � CONSTRUCTION LENDING AGENCY �� � � � , ; I hereby affilm �hoi thero is a constroclion lending agency SIGNEDTN�S � DqvOF � 19_ � � for ihe performonte of the work for which this permit is ��p�° � � ; iasued(Sec.30D7,Civ.C.). . °W�����r� � . � � AODRE55 � ' - Lender'a Name � � . � lender's Addrau ' � - � � '�. I cerlify fhqt I hove read Ihis applimrion ond s�a�e Ihot the � . - � � � � � � � . . - obove information is correct.I ograa b comply with oll County ' - - . � � � �� ordinonces and State lows regubti�g Plumbinq ond Sewera, � - � ��� . � - � �� � � and-he�eby aulhorize represen�atives of this Counly lo eoler � � � � � '. upoo the above-mentioned property for inspec�ion purposes. � - " � . � � � � .i Signoture of PermiHee Da�e SEE�EVERSE fOR E%PLANATORY LANOUAGE . � �......__. .._.._._.._. . . . . . . � : .. _._.. .. .�. ' . _ _ .. � �HSFeao�'s�:ores O�i'NER-AUILDER DECLARATION APPE;OVALS o.�*e Msoccroe's si6Hnmae.. � - �I hrrc6p aL`irm that I ani ex=mpt from tF.i•Cor.va�ctor's ' - � � ' � Li;ense I.nw for�th�,fo'.loe:ing re�son(Section 7031.5, NewHouseS=��cc � � „ pusir,css cnJ Prr,Jessinr:s C.o1cJ:An�� eity nr munty �, CnnNeanPcrtioNat . . . - tvlicl reqairrc e prnr.it t�cnrsstrvct, al�er, inr�ror�, _..... . .. .___ . ._ .. . ; eutwiNe Oe v;osK... -- � � � � � dcn,ofi_ih,nr m;�ir tr.y str:�ct;.rc,prior!o its irs+mntc, � � $EFiIC TANK$EFP FI•�$) ' • • .. AND/ORCRAINFIElO .�._. ._ . _. . . . . ... 6l0 �cg(tiFfJ t�f�4fr�iCG^.!fOf tttCJJ rCTf)ttt !O flrf 6 . � �� - � riqr.cd sfa.c,r.cr.i 1,Sa!hc i.r liernsed pursuant to thc ' cts"oppi❑ oRrxEu Q � . � . _ - .� � " �� � frovirinns r f�l��Cor.trnclnr's-f.irensc Laa�(ChnQtcr 9 , __. . .__ . _.. ____ . ... . nv[a,sEvni�,scv+[a Oe � � � � - �� (commrncir.g a:i!G Section 7000J of Diveiinn 3 of the � . � � . �_srnrrs cr.d Prnfe;sinnt CodeJ or tha�,hc ic cxemf�t � SFNAGE D�SPOSAl5�5iEM��----- � - � - qsmNNeci vwG allo � ' �t!crr rom ar.d tl e nasis or tbc cllr ed exern t � Aa A9AND04 HOl1SE SEWER.. ' � . f I F. P��^. y .._. . .'. ._ . .__ oneKwuserTieTaNes❑ .., . � _ ' . � -� � violu�ior.ojSectior.7031.SbycnyaprliccntJorarermit � � sub'cts tfic r?�l:rant tn a cia�iJ nsit nnt morc tban ' s�cv.airrs❑ eess000�s❑ —. . . _ ._ _._. .._. . .... . ' �e p� y J � . . � , Jire 1�ir.dred dof:Jrs(&SOQI.: I �. ... ._ -�--. . �_. . . . . . �---- - . _.. . . - � � - - � .., . - - . ❑1,zs thc on�nc.�of ihc p:operty�eill do[hc work;and � ; i ' , � ��c structure ss na[in�nJ P f r ilor.r�Code•a`T� _'.- . \. .. . ... . ..... . .__ . .. . . _ .. _. ... . . . . Sec. 704�1, b. Jr�Con- , � � � � � � � � � � � --� - � - =-� - � � tractor's I,icc rr Lau�a'ocs n t apply ta an o¢•ncr of J "�--- �"- -� " - - - � .yropert�u�!a build:ur inrproves�t!ercon,snd¢�bo dars �� 'C—. .. ._ ... Q , . . .. . _ . ' . . sucb u•n�l k;,rirelJ fineid�d tl a�asscG in:f�sovements � � ' . nre not rntersc'ad or offered far sale.If, howeuer, ihe . . . . ... .�. -. . .5uildrng ur in:pro�r.rent is sold��oitGin onr year of -�� �-��� --� � -- -- � - �--� - � ' ' � � :.corrrpJ,tinn,-the oernerbui[der ecill bave tbe burdrn ,. � . � - . � , � � nj pro�in,q tbct Gc d�d nnt 6urW or impronc fnr tbe � a'�m3S � � .1 ix� . - .. �. . parpnsc of talaJ ... . . . � . � 3 - ___. I am esempt undc:Sec. ' . � � � ' vi ' " "E}L':P.C.for this reason ` � � - : ' •J . _ . . . � ... ._.. . � - � .' �, , - �a � � I��� ;_ : � a J Date -`I*'i)'� ' v ' � _ � f . . . « 'i �3 � _ Or.�ner ' "��...i . ' 1 c���-Jlee�F , . . . . �. ... . . - . . . � INSPECTOR'S NOTES � - -�- � - -- '�- � � .. .:.1 '., �. ,r � ._ .. . . . . _. . . - . � � . , . . - . . . � . � i�U � ...l . u . ._ _ .. , ' .. .. ,. . . . . .