HomeMy WebLinkAbout1498A (8)i
WORKERS' COMPENSATION DECLARATION -, .
I hereby affirm =ihat'l have a cergflcatepf consent fo self
_ 76nd�3U
e. Insure or a certlficate'of WorkersCompensat on Insurance, or
. A ��<'
_« _ ,_ <
`PER
p 'p �" /� /� T® *�'-
a a c py rhes eof (becfu3B!)D, Lob C.) OF eoB (REv 6le1 l D
f1P1 LI4rM 1 i®1�!' GR'Yl�.�
P`obcyN .7 g''y Company Tt°U7t ®. „ ., .- ,.on _r _
.. - .,
SEWER-`SEWAGE.0ISPQSALL
Cerrrfd E y� 'h y tied
.. _
v nCern4fieq B filed with the county build ng mspe.ctiorT
COUNTY OF LOS ANGELES
BUIL DING A�JD SAFETY - -
: copy
depart enc `
E 15o e i MQ S�Appllmnt 1��'y�*###'aaaE,,,... epan
FOR APPPLICANT T( FILL IN -
CONNECTION DATA -
*I�KCf S
pws
_ `
DEPTH
MANIHOOIE
pIPeIt f
(7hI5 5Q On naetl n�o> TV,ed by fit e,• f •- n
AOCP4S5
REFERENLE
,��
pr�Tilt IS TO o e hand ed dollars ($lOO) Or Ie55)
r ce llfy that in t(te of the wprk for which this
NEAREST �..+ �\� _ <`�"" `` "._.a.,"
CROSS ST c� C/ FY LJt%
LOWER
... ,
TYPE OF CONNECTION LENGTH FROM
P.L. ML TOP.L.
-
performance
p`�erm t s sued shall not employ any person n any manner
-
�.gg�� -��yyp,�
v CURB
-P'c NO.--�-
sa as to become sublect to the Workers Compensation Lows
.
OWNER-.. i1tY�L'{v l7tlC
GRP
CO. IMP NO.:. Joe NO
TRUNK PERMIT.NO' ROAD PERMIT NO..
_,.
MAIL 'L'Tf1 ,t]p� ,2/S (}
ADDRESS SV .FJ _J GJ
I' Date App1lCont^+'t
.., ,
NO710E ATO LAPP I�ANi If alwte5 ma�km� tYn s Cer`fificate of
-- !� ry
lav O'tTl,ilcx. tEt. 5'1� '9 —9 4�-
AFFIDAVIT
[WAIVER EASEMENT RECORD INSTR NO.
DATE
,..
mpbon; yoq s'f"ioul�d becortie sublect to the Workers=„
sof the Labor code,- must forthw 1h
CITY - No
LEGAL-- --I- "`-
DESCRIPTION L07N0 (
pe, on provisions of you
,, nply with such provisions or this permit'sholl be deemed
-
r'/
35
HWY. OR ST.;WIDENING _-
STATE ENCROACHAhENT
` "E r8 Oked x, ys�
6LOCK .BRACT J5 (
NO OF>tL`DG
LOT NOW ON LOT
PERMIT NO.
I` af#I�rm that am licensed Under rovll
p visions of Chapter
SIZE OF
p Al('commencing with Section 7000) of Division 3 of the_ Bus -,
USE OF. n`
BUILDINGS. Sing. Res,
- CHARGES- -
` iiess d�P o ess{qhs Code, and my Ilce se is in full force,and„ _.
-
` "e feCt
�Tr((�����rr��ii rr�r7t
7RTTy��'YY�rT�rt���� ppTT�Lyy CONST.
CONTRACTOR �p+ArT,„{gr,Lii'2AN IKONS 1.
CONNECTION CHARGE fC£'
,5 �/ {� �y /y'%�,{
Llcense N tuber 4 1 4EJS 7 L C CIa SS •L/
ADDRESS. Gtd
`».'• ,M •.•�'.ryry µ-
RD
FGROUP
Q
„Laf'
-''>t +. tt 3^^ ,*-+ 8^' 3
G2G6 ,elQ.echvt6i JJ1.
"`
STRICT" bNT
MAP -'
-PROCESSED '9Y -
V
Cgnfragtar rt'i'�Q Pi1RE'IADa}fe..c6—
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CIT[ Alta LaQ, NO 1 R{� �}
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BK G -
P
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❑ 1 am exempt vndee Sec of the L A Ca
P
.._TEL
STATE " - CL
LICENSE NO CLASS
f (§,
,._
O
f 'lT "� } -
P�umb.ng Code and/oI Sec of the
NO DESCRIPTION OF WORK FEE '
..
FINAL
DATE
'....
��,(�
V
W
VALIDATION
CONNECTING TO
HOUPUBLSC
B 8 p Code for the fgITowing reasan_x_,,;__-
EWER
`D
y.
,., f '�:. ..
""Dole �`
'SEPTIC TANK EEPA E P i OR -
PITS ANDlOR DRAINFIE D
FIN
Z
- ;'
k
HOUSE SEWER CONNECTING T0- -
PRI[ TE DISPOSAL SYSTE
6v
_
L it gnature -
O�Wfl`Ek 1�u `ER T7'E°CLAItAiON "
1}}
CONNECT ADDITIONAL BLDG Olt
'WORK TO HOUSE EWER - -
4
'OVE(EFLOW
e _ ,,, .»
I hereby affirm tFtat Iqm ixernpt r1cm the -e 5_LICenSQ = M'
SEERAGEPIT DRAINFIElO
EXTN CESSPOOL,'D72VWELL, MANHOLE
-
F
---Low for the following reason (Becton 7031.5,. 8ulsne'ssand Pro
ER, 111,111 0"A6ANooN HOUSE
I .� - -
'"., ons Code -ER
OR DISPOSAL 5v5TEM_as
owner of tie property or'my employees with wages ascompensat
on will do the wo k'and the orycture �_ .,2.%,
Qnotintened
or offered for sale (Segton 7044 Bus ness
Ifiofesaons Co _
Permit $Il�,fi��and
WNIMS
e}
as owner of the property am exclusively contracting with
ORIZATION _
TOTAL FEE _.:
2
S5d COnf ci torstoConstruct the project (SecfiOn']044,
T THIS pAiE A CONTRQCt N(ITN THE HEREIN 'fflCME6 C07J�T,R��°4.C'r6R T(�d
L-E'S
PIOfe5510n5Cocie)
. ,vtw. x,u.-�,h'
THE ABOVE, NSCR16EO EXISTING DWElL1N('i'i0"t7fEi'D61.iC^PEWc"R`',�,
DAY
_,..s.,
11tere p'affirm tha>ta tonstructlgn Iendng agencyR;
HIS
for the performance of the work for which thispermlt IS
GENT 'NIssued
(Sec 309Y Cv C)
"Lkeltalftll C> on
Lenders Name
ry
fih
,l Lende s Address.,..,.. ,�,,.-,,..
,. , ,,.P..
I certify �4hat h`haveregdthls dppllcation 'and store
.,w..
on
`'IF"above informal is correct,, I'agree to, comply with all County
' , ord ances and ;tate laws regulating -Plumbing and ;Sewers
-
` end hereby authorize representatives of this County fo`enter
'-
,', upon ihepbove -mentioned property for inspect on purposes.-
��' -AT
S gnafure f Permittee Data
� 5E�'YI�V"k`Yty"E`F<YKiRl'�ANA70RYLANGUAGE _
-.
''a`4"fAA"
.
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::. �:: ...
.
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A 1 ':: TM` '++ ai `�X'� a' 'r�l .nom-,PiSPECiOWS NCTS
/l_s�xB
ODN:R-BiILDE6TION
`s'i "' _. y
_ LC,.ryA.,�1}1:.[♦}
APPROVALS
DATE. "- INSPEdOI 'S SIGNATURE
. ...
$ hereby affirm that Z am exempt fts.9os the Conttact&s
NEW
NEW HOUSE SEWER
Y � :,
K'u
t@ason (Se Cti070 %O3f..g,
L •. ,"'.
Busch
:.. _ H maws ane$ Prufessvons C y city yr tonniy
Vie$ I �q
CONNECTADDITIONAL,
ADDRIONAL
BUILDING O K
. -
requires a�niou0
qui p Constiwt ; aYder improve,
v SEPT K, SEEP, PiT(51
- ..
.. , d¢malitha' 4r. repair any st/mmCCnrei p9sor t[m YRS imYfea9lCee
v- AND/ORDRAINNELD ...
.. .. - .,
„�,,.p
also . gaires the applkme for such pervnit to fae a
CESSPOOL DRY1NElL-❑
signed. Statement, that be a .licensed pa9•siu mmt to the
provisions O,f Blee 'LOntY®Ct6F'3' LYnGhace Z.aYJ (CRM�mteO' mJ
ALTER, REPAIR SEWER OR
SEWAGE DIM
- ...
(Commencdng udgb Section 717®O) OfDhd.;ion 9 Of *be
y+.. DISCONNECT PLUGANP
Rusinas and Proley�ariOq�ns Code) or that be AR exempt
•:
.
a » ABANDON HOUSE SEWER ..
BACKPILLSEPTIC'TANKS El
,
,„. therefrom, and the Vasal for the alleged exemption. Any
._.. m%olationLeSectio¢ 7031.5 xiforapermit
SEEP PITSI 0 CESSPOOLS ❑
,. b.a ygpfic
s"a�e`t`
ti r
pend more
red d
$and
_
nt
d Ih a fStbe ptavpe don the Screrk
?'
i
. notedC
tended
(Sec 01441; u s d P f lbb— r
tractor License does got apply to an -o{ of
"i —i-+� '
who baalds'or astproves ibere®n, and wba do
x
such work bsmseif provided that such improvements
aro nol mntemxled ,r offered for sale. df, however, the
a
bunking or Ympmavement is sold within ate year of
COMPletmon the ownerrbaidder will ham the
[b.,eardsn
that he did not build ar improve for the
L am exempt under Sec.,
remon
_
77
777-77-77777 ',
Date
6MSPEOMS MOTES
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