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HomeMy WebLinkAbout1498A.... ., - i 1 t ,=+na.t.iuwx WORKERS' COMPENSATION DECLARATION -, . I hereby affirm `shot"I hovp a cergflcatepf consent fo, self - 76n`d�3U e. Insure or a certificate'of WorkprsCompensat on Insurance, ori . �. __ ... ` ':nC a a c PY thereof (56ecfu3B!)D Lob C.) OF eos (REv Blell p 'p�" /� /� T® *�' p.�A f1P1 LI4rM 1 i®1�!' �oR GR'Yl�.� _r P`ohcyN Company' st Ptun ,-. - `. ...... .. °' SEWER SEWAGE,.p1­p�SAL _ '.. Cerr�.� 'h� y tied v copy B filed with the county trulld+ng inspection � COUNTY OF LOS ANGELES BUIL DING A�lD SAFETY - - .�Cerhfied depart enc `` E Dote M FQ STApphmnt Freeman FOR APPLICANT Tb FILL IN - CONNECTION DATA - IN UCIII Re E _ ` STATIONDEPTH p pIPeIOi f*I�KCfS ed by tit e,• f•- n (7hls section naetl no>,,C�t REFERENCE . pr�Tilt IS fd ote p hand ed dollars, -($100) or less) . ., .. .. r ce city that 'n 1(te Of the wprk for W}11C,h this ,`� _ '° I " Cry ... TYPE OF CONNECTION IENGTH FROM - PL. ML TOP.L r - perfOlmtlnpp p`�erm t s sued 1 shall not employ any person n any manner -rY -��yyp,� [ADDRE v CURB _ NO --�- sa as to become sublect to the Workers Cam Lows .. i1tY�L'{v l7tlC ANGRP CO. IMP NO. J08 �O .,.. , ._ TRUNK PERMIT.NO' ROAD PERMITNO.. _,. .:. -.M �.,.. ry'Tr� t]p� ,2/S (} SV .FJ J GJAFFIDAVIT L' Date App1lcom^+'t TEt. 51� ('^9 4�- WAIVEREASEMENT RECORD INSTR Np. DATE ct to the Workers of the Lpbor mp5} forihW th -leiO'tTl,ilcx. No ,ry6 L_,-,_nrovjsions L07N0 cot{e,- y0U with such provisionsor thispermiT shall be deemed ,..,HWY 2 �/ 351 OR ST.;WIDE_NNG_nply STATE ENCROACHMENT'S 1 ` "`�""� � C .. SRACT NO OF>1i`kGs NOW F 9 PERMIT NO. - � s,. ;» ' y " `eb X=' er.,Y,. n licensed ae y p visions of Chapter ; I` b af#I�rm that am licensed Under provisions SIZE OPLOT _ t% `commencing with Section 7000) of Division 3 of the_ Bus USE OF. BUILDINGSSing.Reg - CHARGES ` iiess d�P o ess{qhs Code, and my Ilce se is in full force,and„ _. - 7RTTy��YY�rT,�TI���� ppTT�Lyy ��Tr((�����rr��ii ra�77 CONTRACTOR �p+ArT,„{gr,Lii'2AN IKONS 1. CONNECTION CHARGE fff' /y'%�,{ LICenSe N tuber 4 1 4SJS 7 L C Class •e, ADDRESS. QrG11W©Gfd `».=• ..M •.•�'.ryry µ- RD FGROUP Q „Laf' -'iW '>t G2G6 ,elQ. JJ1. STRICT" bNT MAP -' PROCESSED- V COn TIa i r F'pgF+iTtRtl Dante .zc 6— �'7 CITY Alta LOI�Q, NO ""'� L BK G - P I am exem t vndee Sec of the L A Co P � .._TEL STATE " - CI LICENSE NO. CI O P�umb.ng Code and/or Sec of the NO DESCRIPTION OF WORK - FINAL ��/�,(� W VALIDATION CONNECTING TO HOUPUBLSC B 8 p Code for the fq'I7owin I reason EWER 17 00DATE `D y. - - - ,.,'SEPTIC TANK EEPA E P i OR -w,__..,_»._ -.. PITS ANDlOR DRAINFIE D FINAL Z ` ':- `3P- -BY 'HOUSE SEWER C60NNECrfNG TO: " 3 ' FRIV TE DISPOSAL SYSTE - ,,.. ... ...- ... - - J rSlgnatuYe - - OWf 0 0`�I}�R T7i�'CLAIiA ON CONNECT ADDITIONAL BLDG OR ,. 'WORK TO HOUSE EWER w 'OVE(EHOw ®" e ,„,< .c u�. _, x .. _ ,,..:t .» hereby affirm tFtai,l,.grTt eXem pf"from the fa� ItraCfa_ 5_LIConSQ _ , M' SEERAGE PIT DRAINFIELO EXTN CESSPOOL,'D72VWELL, MANHOLE - A - Law for the follow n9 Tease (Secton 7Q31.5, BUlsnessand Pro , „ ; ALTER, REPmR-oR ABANDON HouSE I - ­AIs Ons Code - SEwER OR DISPOSAL 5v5TEM- P as owner of theaproperty, or my employees with wages as -r thg sglecompepsat on will do the work arid the structure _ ,j r 2 7,5 Q - s not.+ntended or offered for sale (Section, 7044, Bus ness Coe} OWNFR'S Permit $ Il�,fi �0 - and P-rofesslons ❑ I as owner of the property, am exclusively contracting with - AUTHORIZATION 1 TOTAL FEE _;' „ 2. �, c 0 - - CBnSed COnf a'&ors to construct the project (Secfion'.7044, 1 HAVE AT THIS DATE A CONTRACT PITH THE HEREIN 'NEAME6 CO'IWTR CTOR Tr� ”' _ ee,, [� r; U r) 2 y 'E'„8 6 - ESUS neYss End PIOfe5510n5'Co, ci'e) ' CO�hl�„, CifON lE�l'YSINi ANCY ,.` .. ,.: CONN THE ABOVE;Ij{5CR1BE� EXISTING DWEL6ING`i079E9sD8{iC $EWER` �, ,'... DAY -�,h' _,..."r.s.,,, I here y' affirm 1haffhEie is aponstruchgr1en,ng agency ED THIS ERoR' , for the performance of the work for which this permit is ERS AGENTISSUO{iv C_„ w ' Lenders Name ESS11 ,) Le s Adess<1 , , ..,.. certify4hat h`havereadthls ”",F" above information Is correct_ I agree to comply with of I County- ` , ord ariceIs and State Taws regulating Plumbing and ;Sewers - ° and hereby authorize representgfives of this Cqurity fo`enfer ^` '” "" "'-"' ., the above mens oned property for inspect on purposes. - ' S 'nature f Permittee Data -� 5E�*V"k%ty"E`rF<YKVXVCANA70RYLANGUAGE '>'� �y3 �.ks,�+ rM'S *'5�&r s,.'�e� x % �k�* w sem".-�,kt +*r` 3 Wrh s',+ ��'a{"�ti{c� � '"S' R^r¢ �- 4' rr��: La a.-# - t ..a„.a! ^•