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HomeMy WebLinkAbout1504A (8),••.P .., -^-- 4 .� tai v J- 9 K,doi ^Ti, n. s`6" '�..A"s t ,ry S F ifP. } V` i'. 6 { r .-: WORKERS" COMPNSAT�O13EC�l.{R/�1`ILStJ" .F,.' f Sonsent to self I hereby _affirm that. ( hgve a e*rifcate o „^, _ s •""'"58'K6a'36" I sure or a'certlficate of Wo ke s Cam ensanon Insurance, or" - D P ( ) ' acertfe 'r` f Sec 380 Lab C. ceenswsvBiell APPLICATION FdR. PERM' - PohcY 11 �a t • FUn .., .e ._.r _ ....,.w .. .... ....... w.> Q cert,fi ereby tarnished with SEWER_' SEWAGE DISPOSAL i is filed the count building Certified copy y uilding inspection COUNTY OF LOS`ANGELES dea%GVf 8i2'�P�i1clYJ Date Applicant CERT''(F'ICATE OF, E M�'rI N FT2S i Nlbnl2-`KER'S FOR APPLICANT TO FILL IN CONNECTION DATA BUItD NGD- ' STATION EPTH 'CbNLPEN'AfIQ(J IFiSJ ASCE" ADDRESS-I ' '.C�l - section need not be complete if the wdrk mvolved,by the UPPER LOCALITY MANHOLE REFERENCE 9CO. �(ihts permit is-for one hundred Bolla s 0100) or less) - LOWER LOWER �. ::. +. r .-o•... .,. .w - certify that n the performance ofthe work for whih this, Y TYPEOF CONNECTIONI NEAREST CROSSsr,.. permt sssued I shall not employ'any person in any manner CURB P L 'r�µq�� -abecome sGbjlect to theWorkers Compensaton La S - - ¢M A� &> �V� n}" OWNERAICD{ T GIRT - IMP. NO. - JOB NO V - D R;; .. �_. TRUNK PERMIT NO ...ROAD PERMIT NO. ESS Qat pp iCanf l - _. ,.„ .,,�x..�.+:. '_ - NOTICE 1"O A`PPIIC C T I# after making -this GerrlfiCSte of '- AFFIDAVIT WAIVER EASEMENT RECORD INSTR. NO. � rE}. No $ $ 6 DATE ' _ mplior you should become subject 'to the. Workers' ertv ,©�rJna LEGAL ' - pQns'ation provislons of the Labor code, you must forthwith I nply with s be, deemed DESCRIPTION LIOT NO HwV OR ST. WIDENING - - such provisions gr.-:th permit'shatl c - ,. 3 754 BLOCK " 'TRACT STATE ENCROACHMENT re Oked _: ,y p qqd CONT�ACfORSDD�CL#ATI, ". �. N6 OE BLDGS PERMIt NO- Lf ,E, _.oma a. a ,;, �, •.,r I hereby off rm that tam licensed us er pTOVisia' of If . SIZE OF LOT NOW-ON LOT 9 (commencing with Section'7000) of Division 3 of the Busi - LIST OF DUIIOLNGs CHARGES - - - ne5s'p d Professwn$ Code and m license s in full fort h - - y force and , - effect q y CONTRACTOR e' eman f;O21 L s - CONNECTION CHARGE FEE''- - y. r aly a r+�ryq . License Number, d. f [LLSi] V LIC Class �y - _. pp r�D� �ry y, ��cc�.,,,,,, REIMBVRSEMENT FEE ADDRESSS-r 02 G� Bef?Ck1Wp©� O yL,��T $�%rT / Contractor=+• A' eISM4.R'n Date "�/ 'GO/ 86 1AL" DISTRICTNO �Q - GROVP' MAV PR CE' O $SED BV _ ,L ..c a Y s-, ❑ I Sec the L A Co CITY y TEL N6 STATE.. _11C .. _ BK PG Z .. am exempt under of 9 UCENSE;NO 88 CLASS NO-'I DESCRIPTION OF WORK -FEE " - -'� Plumb ng Code and/atSec of ilia {9 HNAL O DAIS ER 17 t' PUB CS VALID TION_ a B gi P Code fpf the fp o g reason .. tSaie' -S IC TANK,-JEEP GE PIT OR '� _ T9 AND/©R DRAINHELD FINAL CV 'HOUSE Z _ SEWER CONNECTING TO Signature - CONNECT ADDITIONAL BLOC Ort _ -' OWNIFR BUi("d it DE�1,AR%AI IQ�d �6 WORK TO HOUSE 5 WER - +' x I hereby affirm tlipilham °eR'efrl pf from }lie to nlracipr, sLicerise'-ExTN., OVER LOWS PAG PIT, DRAINFIELD cESSPooL, DFvwEtt. MANHOLE Low for the fallowing reason (Secion 7031,5; BUishess and Pro - ALTER, REPAIR:OR ABANDON MOUSE -- - b 5 S�Q,' �1' A SEWER OR DISPOSAL SYSTEM'" - - - - as owner of the property; ar my employees with wages as 1G theif sole compensat on will. do the work and the structure - - d for safe {Section 70, Buslness is not intended or offere44 - - - - .-i o ,o'%, 5. Q, ' aKd.,ProfesssorISCode):- - -' -: OWNER'S _ Permit - $ 10.50 I as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE 27150 ° 2 75 Ox licensed cont actors to construct the ro'ect Sect on 7044 Project ( '.-, BUSIT18S3 and PFOfeSSiOnS COr3e) I.HAVE AT THIS DATE A CONTRACT'OATH THE HEREIN NAMED CONTRACTOR TO - CONNECT THE ABOVE.DESCRIBED EXIST NQ DWELLING TO THE PUBLIC SEWER - c&29-86 —""ry t '+: c �ON$1` l�C7l`ON L"Enfipi'h' A fN "•" ✓�. �% G I hereby aff rm thatrihere Isd construction lending a`genc'y SIGNED THIS OWNER OR - for the performance of the work for which th s perm - -:: it is - _ OWNERS AGENT - ,e ssued (Sec 3097 C C) - - S „ z Lender s Name ADDRESS in _ - Lender sAddress - ' 1 I certify that ( have "read `this opp(ication ono state"that the above iriforrrlat on is correct. I agree to cornply with all County- ','.,'. ord`nances and°5'taig laws-regulating-Plumbing_and'$ewers, - ..,,; and he e6y authar(e representatives of this County ,tg enter flponabove-mentioned for - - - property Inspection purposes. t. - �, ., Signature of ermitiee Date - SEEkrtVERSE10191PLANOORV LANGUAGE' - "' ,dam"11 Y4 v aispEcr®les "w" OWNER -BUILDER DECf �1 TION APPROVALS OATt INSPECtOR'S SIGPPtURE NEW HOUSE SEWER .. W NN ECT ADDITIONAL - BUILDING OR WORK SEPTIC TANK, SEEP, PIT{SJ _ AND/OR DRAINFIELD CESSPOOL �' DRYWELL Q. ALTER, REPAIR, SEWER OR SEWAGE DISP65AL SYSTEM DISCONNECT PLUG AND ABANDON HOUSE SEWER BACK ILL SEPTIC TANKS Q, : ' SEEP, PITS ❑ CESSPOOLS.[].. .. I hereby affirm that I am exempt from the Contzactor's ... -.License Law for'the'following reason (Section '7031.5, ,Business- and rrofessiow Coils). ° Any city or county. .. .... _- , which ,regreires a_ pernsd to construct,',. alter,. improve, dsmolfsb, or^rspAir any. s ; prior to, its issuance, :_.. also . requirm the a"licent for ssacb ,Permit to: filen '. signed .statement aha* be is U"ased pu in"t to the provisions of the Contractor's Lcense Law fCbapter 9 ,- (commencing with Section 7000) of Division 3 of the Business and, Professions Code) or that be is exempt.. therafrov, and the basic for the alleged exemption. -.Any. violatia'a O Secteors 7051.5 a f y, pplic'antforapermis subjects the appkcant to a civil penalty of not more than XS s.Z. a five hundred dollars 1$500).: ` ,5�,=:....Q .,: _... Ell, as the owner of thepropeny will do the work, and - - .. £ the structure isnot intended or offered for Sale. frac neas aced Professions 4; B� i .Profess Code T&-�4m- 1 tractor's _ w does Xot to a o' >a ?,C 1 C>� .. - _ � silt Merton, and wbu,doees who bunds or improves Pt'op ... 7__. u t such work elf provided *bat sucb improaTerasnts '. �._ '. - '¢, or offered forale Ff,, bowever, the bus ng or provemant st so within one a of ..• - romp tin, t e oum"4Wfd w will have the rden , r G. F q of proof tbat'he did not build or'improve for the . .. _Fin j pa rTpm salt ) -j"1 � 1 r 1;r ? 5 C x '.. INSPECT60t NOTES ' q- d 7m�- kr"`3»iYfi5,3Pi?1m+5`£PY,.a.. „:^&r�