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HomeMy WebLinkAbout1496A � ^a :f �.' ,a�, �..�z �,-e ��, .�a�t�+k F'��1k•kW -�' U s�, re{�'k+.,ck rekaasr�s:;"�C T,�'i,�'3Y.a,�w.aa�+�"k^-^°-es ,�«.a :. �,d � � -: 2 3�- .� -m' F� l� a' z P -; . x .. �I .�=WORKEqS rC0l1�P�135A"fION DE��fCf2,4TION � � � ' � ; , e , : a-P �a�� .;. ,zv.,.,,. �..� : : .. ,..v��. ,. r . , .� . +cvr� � � . � . � i hereby affirm tFiat�.I have a'cerhfcate��gf conseni'vo sel� _ _ ., „ ,� w , , ,,, �,�_ _„. . nsura o�a ce t fmate of Workere Com ensphon Insurance,or � �A��� - � �� y"�ce t i d o y thereof Sec 3800 L�oib C. c eaa(zgv eiei I p�� " � ❑CerNfi , � s rebyP���,�8h.3-ti.��tal�� • . � �, ,� SGI.�RAT��N ��R, �EIVY��T � �Polic No, om n �s _. . . ...._ _.. , � W - SEWAGE D15POSAL` : _.., �.u. � , _. y . .,, _ ,' �Certified copy is fJed with ihe coumy building inspection � COUN'rY��COS AF�GELES BI��lDING AND SA,FETY' _ _ . . .,.. ... . : _ � _ �� depdilmeN . . .� . �..� . . , . . . ,� . . . . .. . ,. . . . f` �a�Ye�_$�_i,pPi�anr . jP���mati FQRAPPLICANT TQ_FILL IN CONNECTION DATA S �'�ER71FICA� OF� M�r�lN bM�/JORKER5 g�{IlD N6 S,ATio� -�.. ,, ' oE�H ' < �s�. ,�a��^�c���1�1��1�ih1S�,�N'"�� nooaEss ' : a ,u { � . (This sect on neednot be completed if i�he�vo�nyo�veO,by fhe � - � - � � MqNHOtE REFERE`VCE - l7PVER� ,-. - ' IOCALIN � � .. L WER }Serm t is for one h�nd ed dollars�$1001 or less) . NFAREST - °, � 7ve[oF oNN[cnoiv """�- `�"`""`"'�" "`�"""'"":. � I cerhfy:thaf in IFe�-�perfoimance of iheAv,�.or�i fwr wfitch ihis � .�,� � � ��� -- � . � �ErdGniFROne „ .. ,:; , 4 _.. GRO55 ST.. . V. CURB.:�.� . P i , M t TO P.L ��, peWm t ir issued I sh011 no7 employ any per;on in any monner . � - , . . � "`""` ' " "` �� so bs Yo became sub�ect to ihe Worke s Compansdt on Lows OWNER 1���'a� C7r� - Co iM7.NO.. � ��Oe No, , �-,' q�..r-cs.�,�s�;�,�.�."�.�?������4�,.. '"'m��a�;r� '�-^Y`:q. nulr_ ,.. . . . _ . � - - -- � � � `�"� "�'¢ '� '� n� � Ap�RESS � '� � . .. 2 -�- � TR�NK PERMiT NO �ROAD PEFMIT NO. - ' Date �� �iPp�canf �, �� ._.. � . I � 1., Vr "� , 4 � -'� ._ .� AFF@AVIJ WANER EASEMENT' RECORD IfJSiR.NO. 4AiE' � '. NOtp�O ✓'i�pPLisho d beQome.mabject'f�ro heli�ate o��. �:�.� arv.. nwC1Y'lllc`� �T�t N� � �� 6 � .� .. � , 9 orkers' ... .. _,.,...:... . ... ;���y"'cns5r on rovisions of the Lahor cnde>yau musr foethwith . � oescRi i�ior� ���orn�p � � � �- ����� �- . � . HNN ORST.WIDENING . �� ❑ply witR such prowsdns or)h�s perm t shall be deemed r7 A � � � � . . .. ' f8(�Ok2CI ' � BIOQ(_ �TRACT . ��1�7 STAIEENCROACI{MENT �� '- , : �r,y-�� l '.�Y�+�SEb�Ot�T'f2"�`C7C�R�D�C�A'(FA��IO(�" �- .;`_.•. � � rvzs oF eio�s � �B^^�T No: ` t .i., aara��.f�.„>s.�. ,,.e.�,.N SIZE OF�lOT NOVJ QNfOJ .�V . ._ . . _ ' I he eby aFf m thal-am ficense�under�provisions of'�hapter �� u5eoe ' �� ' �' "'" '�� - � with�Secnon 7000 of Drvision 3 of ihe 8usi gUiIOINGs c�7�-Il�.a ��F'i-• � "� � � � "cHnaGES �'���� ��� "��-"-� , 9(commer�c ng , ) � - ° ' � hess aHdPtofessions"Code and��my Iwense�s in f�ll foice and - � - � � - ---- �- �- � �� - ��-- �- -- - '-` �f{BCi ry�h�� �7 ' � CONTRACTOR ��1 R� � � � CONNECTiON CHARGEFE �. , � L CEnSC�lU be 4 t Y��f �L C C�OSS ��� .. .. . q r� , , y, . .. REIA1BURSEMENT FEE . . � - .��^-. , .....��.�.�. ...�. ..,. E' t a r� ,. AnDRE55 VZG BCL1W L�: - '. . � • .�.."�f ��` Y�fi '� � GO S6 .,. , ". . •..� . ..... DISTRICT.NP 'GROUP... MAP�� PROCESSE6�BP`..; � ContracYor s 1'�em8Y1 -Dcrte�� qtt��. �iei N � s '�a k�3�.�.� .�+.s 4''?r,:�Z.� x :. 7 . eK . .rc .. Z. , .. .. o �,..x'.3� SFATF�.. . �.- �L�_ � /?1 � . " ❑1 am exert�pt under Sec of ihe L�A Co uceNse No. .. � � �.c�nss �- �j�v ., . , .. � . . ; , . . � � z �, r ,+ . . F '.. PlumbngCodeandlorSec ofihe �- "p--�� DESCRIPTf NO,WOR. FeE . fiNA�..� - . � �U ` � 3' . HOf15E SEWER CONNECTIfJG TO, DAiE ; A a , VALIDATION a ; � v ,� � �s , „ �z . �.. � . . . lJI�"0 ✓ ,�v .- :,� B �"P �ode for�Fre f"ofbwing reason PuauC stweR"' � " ' -` ' �.� �Q /!r ,�,>"� . � u'� - SEP7ICTANK,'SEEPA6FPITOR"� .� � � � �_ =; �`i n - �� � s � � ,?��w;. .. �ertSnNtlio�t�aw�.ilvrveib � � FiNni - . , �._ r x . . �afe�—,--.,-c+— �H01J5e5EWEKGONNErilNctO" sv ���� � x 4 - y t' �'.':� � E- 3 ��.PRIVRTE 61 SAL Y TE ��Igrtptu e .' �� . " �CONNECT'AD151TIONlfC BCDC::¢R . � . . . ���� � iheffo low n i�asoXn Secton 7031.5 Bu sness an � � �wo�K roN�t55e scVc+ek" " �' � . - - . ". -�",� a 2�5�_7�R BUIL,{��CL�'�'AI�°11�N � . � OUtRFLOW SEEylnGE Pli DR.kINFlElO " 1 I�ereby �J ICenSe . E%TN CESSPQCI,DRVWELI MANHOIE � � � -. ldW fDf g ( C�P O � Al1ER REPAfR'(1R AOANpON HpUSE � - � V�...'�+.OhSCDI�E� * ' � � �SEWEROa��ISPOS"ACSYSTEM : ., . . . � � L, . .. .. .. 1,as�owner�ofihe property,or my emp�oyees with v✓dges as� � � , i ������ � � ,* the rsole tompensation,wili do the work and,.ih,e sicucture . .-_ � . ' � � � � � . �.¢ �.o�o..'� �. _ is no�i�tiended o�offere�l for sa�y(Sflction 7044,Bys�ess - � - � C - � ��; and Profess ons CQde) � ._ -�, ... -�D�VN(E$'S Permit $- ♦'- � , 6 p�.�c��. ❑I as owner of the property am exclosively qonira<)ing with AUTH�RIZ�TION TOTAL F�E `�7 �j� .._., � - z_. ,:' t I censed COnlfpCfOfS f0 COn51,Yt�Cf fh@ pfOjeC1�$0Cti0��4-0,„ I HAVE Ai iH15 OATE A CONjRACT WITH Thi�HEREIN NAME6 CONTRACI'OR,TO . �� �'-��f;-'WY,t}�; � � fOleBhe Y Bf���C��h��Oe����I���AW��h�dsn(� agencyR� .s''�n S�N E�pR ISABQVE'PEb�RIBFJ7 ERO ING DWEILING TO TyE PUBl1��,'yVERy,,.. � � �., t r .. 4 . � . . �4 . .. .�" S'� '" : .a OF 19� . . ... ... . . � P . ,. . Perm t s nWNFas aG�t . . . . . .. �r ► 9v�6 �,� issaed(Sec 3097 Civ C) ' � ' -- '� '�'���"' ,�,` ' t ' _' '. y :. �.. ADDRESS � - .. ; Lender s Nome ��� � � � � -� � ' ,.3 ..» ._�, <x,. _�� .�,...�'' �'_z� x,�`....:".._,-a.,.� ���'��""'��'�.���'"'"�t��`����..»,��`�-���uL'i'�*� �*�r�,��'-` ' �� �.;;t t ,.�,� �. , .� lender s Address �- ..� � .;. � . ,..,.._ .,.,s.,_ ., �..... .-b> b..� xA ,:.�. .-:_., . . _� , , M . ,. N,k. �... � u...s . ._ .,,_ "._ _>.:.� b.»..,�.,:x ,.� . ,.�� ,..e.� �1 .�,. - �.� � .� .�..r w.�;: .v 1 ce hfy'tbat 1 have`reatf t�his app imt�on and stme that the . , � ,. � . ,,.,,.. � , ,-- ... .., ,._ . ., , . ;� ._r .,. ,_ . abo e mfo mahon iS_co recf.I a rae to Somply with alf�County � _ � ` � . � ��� arcTinances and Stote fa s regula�inq P7umbmg and Sevt�ers, � �='` ' ' �� ' '� � - � � � ' and f�ere6y author�ze representahves of this Couniy to enfer ,� - " �" ' � _� `'" y�yan ihe above ment oned property fo inspechon purpose5 � ' � � � ; ,�+-�� ,� s d�' .._�...., .� .. .: , ,�. ,� . � : � ., ,: a . � o- . . . . . .._ » ��•-- �r9'� S'�l --�"`�^'�--- � �, U,_� , <,..,. w,_._ . �, . .; � � g .:: .._ . �,.- . XI�tAN'd1"$'kYC�"15C:U7C:E� ,. . .. ,. . ._ . .,,_ .. ,....,.> ...... __... ._ � , . ^.. , .� _ . . : _ .,_ - . S natureofPermittee _ Dafe SEE��'�iR E�OIt€