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HomeMy WebLinkAbout1492A (8)_ WORKERS COHtPENSA'nCf4 D1'CLAli nog " -` hereby of{Irm that l 'have a terhficate consent o -, Igsure or o cerhficate,of Workers' Conlpenkojlon 1nsurIance, or bA�Yzb , a cert f thereof 3800 C) ' CE Bqs (REV.s/Brl gd cop (Sec _ CLeab p�o-Ti cy YVCompany .S, t. F�LMA. APPCICAT104 F�'ISR L1y Certw ,r erebY furnished ��y�Il „SC�/"��7G �V�1✓.7, /'�`�� �� �� -y 3 Cert f ed cop is,filed wdh the count building inspection W y Y 9 p- COUNTY OF LOS ANGELES QUI{ DiNG xx SAFETY 1 - 86` Freemazt ... yW Y ate Applicant ..... t _,. FOR APPLCCANT TO EICLIN"" BUILDING - CONNECTION DATA CZ KI %ii1V (STN' SVK j ADDRESS i STATION .. DEPTH (Th s sett on need not be complete' f the wor7c n ofved by the 9 V MANHOLE REFERENCE ' UPPER Serm t 'for one hundred dollars; _($100 or less) Locnu7v _ __' O ;- certify that in 1 6 performance of the work far "which this "piermit NEAREST caoss'sr .I TYPE OF CONNECTION -" LENGTH FROM - Is issued I shall not employ any person inany manner., Y - CURB P L M L TO RL "`so as to become subject io the Workers Compensat on Lqws 4f,`T`rW OWNER - - P,c No. - co IMP No.; 5oe 'ixyr". dEY.�F f': .' P - F - -. NO. Date a ADDRESS � � � ' -' DC TRUNK PERMIT NO ROAD PERMIT NO;.. - - - {,�Ay�pypT�'cont _ �IOif�'E Tri AYP ANI �fA a�ter making 1 eeffif ca)a Of� ' .« O^{ p C +I '.. CITY Covina TE, O (7.EV V _ AFFIDAVIT SEM RECORD INBTR DATE VIT WAIVER EASEMENT R NO ptiorr, you s'lToulall become subject to the Workers .L LEGAL pensatlan prOVISIOnS Of the labor carie you must forthwith nply With such provisions or this perm i sha(I be deemed DESCRIPTION _LQTNO HWY OR ST WIDENING - - 54 fevpked .�.. y - 41".t' 3T:�L1� MS`61CO' 'ftRAC`I' � 1" .•....1 BLOCK TRACT NO OF BUX S - STATE ENfROACH}TENT PERMIT NO - } ° Sk Mss-..rovisions .; I here ecensed un f SIZE Of IOT NOWONCOY "' Ico mens ng th' Section 7400) ofeD vision 3 of the Bas USISOFNGs 4Vd;P;Clessions-Code, and my license i's;in fair force and - ,CHARGES- ,` a{tett AA q ,t ay q - „ License Number Y f ` 8 1 Lic Class 3y{. CONTRACTOR CHARGE FEE +�,, Contractor l+'rBman Date© ADDRESS -' NT FEE GROUP. MAP -' PROCESSED BY'"" O 1 am exem 1 under Sec A Co CITY " ifL NO . VINAL - eK PG STATE - w. « 4 _ of the L L �# p i ✓ CENSE r.o 14)PS class �i O € plumping Code and/or Sec the NO DESAACTr2YfPTlON OF WORK ' FEE////p U of :`F w w" :1," ,4 # ✓N a+ Y-$ M*T�,a:Si F .+' S y J& i P COde {Or The TOiowing reds 0Tt - - HOUSE SEWER CONNECTING TO` PUBLIC'SEWER yVALIDATION W yPITS x1 )y" - AND/OROUSE H SEWER LONNECTNG'TC_ PRIVATE DI5POB'ACSYSTE $Ignafur0 y,, r,� 'T � `2 Sk OWfYER BU�L6kQ �E�LAK�- • ••.. ,i "r5 CONNECT ADpp��TIONAL BLDG b12 WORK TO"N00SE 5ES7ER f i hereby affirm that am exempt,from the Coniracfof s License t w for following VERF[O SE PAGE VIT DRAINFIELQ EJCTN CE55POOd:; tlaYWELL MANHOLE ) E. 9, A the reason'(Secton 703le S; Buisness.a U Pro- ALTER REPAIR oR-ABANDbN yoUSE " ' -"' ` • '- '- 2' .'r,+�e ode) SonsC, as owner of the?property, army employees with wdges- SEWER OR D15P0$Al SYSTEM` '.; iheirsale compensation, will do the work and the structure .2j 7,5iii ais-not inten ed or offe ed fo, 'sa(e (Sectign 744 0', Business' - and Prof"esslons,Code) OWNER'S ' P-1mit - $ 10 H 2T 5 0 6 ❑ t as owner of the propeny, am exclUsively contracting with AUTHORIZATION I TOTAL FEE 27 5(Q . licensed OgnfraCtofs to construct lho,projecf (Section `7044, - HAVE AT THIS DATE A CONTaACI"WIYH' HEREIN`NAMEO rnNiRAtTOR e Business and Profess ons Cio e.) - CONNECT THE ABOVE' DESCRIBEDUISifNGIIWELL7F1�'"YO"IYtFTsL581_1C_$EVJER: CONSIRpCTON LE�I�TNG (OCG 'afFlrm' "' � - I hereby thaf There is a construction Tena, trig agency' the for - SIGNED THIS DAY OF 19 OWNER-bR - - ;Lfor performance of the work which this permit s i slued (Sec 3097 C v'C) OWNERS- - ` "Lende ADDRESS'- tsar y ai t have read th's application and state that the abo e nfgrmatI n,is correct. (agree to comply with all County. - --' Ord notices. aryl-$tate„ lows, regulating Plumbing and Sewers, - `-- - Wand hereby authorize representatives of this County to Enter- -;; uponK the abovementioned property for nspechon - ' Signature oTf Permittee SEE....- _0 u' m . ��R i ` A A75PECTAR S MfOYES " {�i1�llii �811LY2 D A$C81V :. �1p�R���ls iNSPECiiSRS SIGNA�`iYIIRE -'� k IiCPebj effiRnA 41BRY f Bni eAeffi119t from the t.O$tr9CtoR'S __: ... ..��_ ..:.... , „ License-paw W the followingreason f$ecaion 7031.5, -NEW HOUSE "'.. " ^„ ,... -". ;. .. ,..;. - __. ,- . .,.. .' .'.:.. ,., - Business aP4,Prvfessivns Code): Any.. city or Zoe my - ..CONNECT ADDITIONAL - . • - - - ,. Yea 9Permit to COMPWC4,slipr, i-prove ' BUILDING OR WORK - 'ft' -. ® or r sh%t asSre to its issuance, g'ftny or` •. SEPTIC TANK,' SEF P, PIT ) •",• (- ^ _"thr ww - aISO r8s191ss'eS the appiYt, for BYL6b parmit -file O AND/OR DRAtNFiEID - - .... signed, statement that he is Licensed' pursuant to the CESSPOOL..❑ DRYWELL Q • .. :M" ., 7 �"' "`"„ ^�"`�" »,"' rovizwns of the Cowractores Liceme Law tChapter 9 - . ALTER REPAIR SEWER OR - - fc mmencing with Section 7000) of Diviricm'3 of the SEWAGE DISPOSAL SYSTEM,. .: .. Business and Professions Code) or :bat be is exempt gSCONNECE PLUG AND SEWER,'. : .. therefrom and the bassi fOr the a leged exemption. Any - . ABANDON HOt15E ;4 ��.'.. U/Oiati6n of Secti®a 7031.5 by any appliew afore permit BACKNLL SEPTIC TANKS 0- �r SEPTTISI O CESSPOOLS ❑ E, .,,'yam. s *ts the applicant 20 a cseii¢enMay of not Sore th" 0) 1,, ash the of the and rr 9 propertythework, ease is intended offered for� " a structure not or ";o fSec 7044 Basiesit and P:afessions Code Tkr ZractGs`'B License Law does not i to an of of - Aga C property who badiids or srvsprov"es thereon and who does y work himseif provided that such improvements t - are si8i nitteP,dedi os' Offered fes' Bare. ,If, hOw89� tb8 "t F braslaiatg or improveme#i it BOid fUfthPn one yeas' of f com¢1e#on the owner-buiTder aviii have the burden of proving Ghat he did not bna&i or improve for the ¢aoftaie) 'S3X"d' "de.v> { q ^C I A"} iVi}�i�l Y°i•,•`a !'."� ! x- (t�� ..L ti. ds ,fit _ 1 €is:.p gth 3 t 'ry'3F p Ef /� ,[ y_� -,-' S C- for thi1 ieMn 77 Date 9NSPE�TO�°SPOfYYES._ " x , �C '• ,p",N, 7." 3" '{JNP YC .eiS`N. ,�i MP'°.v�s`i+"d` 3' $"+!-.. dz fi( F 1 4 � ^"ef„mGlp.^afF 'pen"'i' _ Wtv,>r^LM1,-wro'i4+YF7%9P .., '"} ,��{ X lit ,� J t gl,� ✓ li. y � u. wtiUO- a TK'.T}ftd W:�h+-flwt 2it,. - Y' - �'; #x^s'>X,r �1 ^.,P°,uhN,.. 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