HomeMy WebLinkAbout1491ARKERS COMPEN5A710t�+ DECL,dRATYON' '
.e ..,
m that I have a carhflcate_of consent to seff = -
t f cote of Wo kers'. Compensat on Insurance,' or" ZeAeaao - -
' GE BOB (REV. B.+Bt
ty thereof (Sec 3�eoD �`La6 C.) y��
ompany 'ti- if'l nd es
M SEWER -
hereby furnished SEV"lift
:opy is: filed with the county building inspection ' COUNTY OF LOS ANI IM
c Involvedby the
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k
sfor wh'ith this
n in any -manner
9PPLIC'AN)It, 'Otter making .this Uertit.cote or
you .should become subject'" to the Workers'
n provisions of'fhe Labor code, you must forthwith -
such. provisions: or this 'permit shall be, deemed,
zr« sw..nart,
'm that 6 m f tenseup der provisions of Chapter - -
ng with Section 7000) of Division 3 of thea s
Fess.ons Code, and my cense is .n full force and _
,or 4 "Lc ClcI
812x86
L^L2ffi$Tl Date
npt under Sec, -...of the L A Co
..
FOR APPLICANT TOF1FJJJr1tN "'" _.qXITIATI..
CONNECTION DATA°
,BUILDING -.
DORESS
DEPTHUPPER
LOCALITY -
HOLE' REFERENCE LOWER
OVERFLOW SEEPAGE %T DRAINFjELD
EXTN , CESSPOOL, DRYWELlI MANHOLE
TYPE' OF CONNECTIONNEAREST _
ST. -
PZ -
P1,'CROSS
- CURB, < P l - M L, P1,
A�Tnr�rr�.X.C-
CNO
OWNER - litYYl ..... ........,.. ,.
CO IMP.NO.- -)OBNO
MAILS 'f16 ., BQ_X- 3127 -. _.
[c]�
ADDRESS '' VV FD3VV .11 G
TRUNK PERMrr NO., - RO''AV1f1iJilt%PJ`.`.`.•'•'.•,,<•••-":.+�..•,"-
818- 67-9541 --
AFFIDAVIT WAIVER EASEMENT RECORD` INSTR NC. DATE -
CITY '-' O�VIYl „TE}. NO
L%
LEGAL
DESCRIPTION LOT NO:
-HWY. OR ST:WIDENING-'-- ' -
r7 ,t
TRACT � 7
Mended or offered~ fpr saLu
le (Section 7044,'_Business
BLOCK -_ j
NO OF SLOGS "..
STATE ENCROACEMENT
PERM.. NO - ..._ -
SIZEOFLOT- NOW QN:LOT „--
-
p:
X.LE,DINNGS -. Sin ♦ Res.
BUR
OWNER'S- Permit E '1C
y��P�EEE �'r �{/�NS ray
CONTRACTOR 1"i11C/.CJF'dAtM .l�Ui?ttD1 K��
CONNECTION:CHARGE FEE -
ADDRESS 82 2 BeREIMBURSEMENT
FEE
�^ ry p
AltaTEL
Al a
DISTRICT NO. GROUPMAP - RROCESSED I,CITY
Loma NO ,L VQ'�.
rr��A�t,pr7_ q.LI
BK PG
�xtt
ENSE NO Y i 4887BE 03`1'NO
I HAVE AT THIS DATE "'A CONTRA(ST'jn'}P"iHE`HEREIN WAMED CONTRACTOR 70 ,,
CONNECT THE ABOVE'DESCRIBED E'XISiI�G'SVSECL(NG`"`fY)?rwiE DUyBUC"S@}YER
-`DESCRIRTIONOF WORT(_ FES`
SEWER CONNECr.NG rO1
PUBLIC SEWER
I
FINALHOUSE
DATE ' VALIDATION - -_
- -SEPTIC TANK, SEEPAGE PIT OR -
PITS AND/OR'DRAINPIEib` -
FINAL. - -
- HOUSE SEWFIE CQNNECTLNG TO
PRIVATE DIS AL SYSTE
BY
OWN�R$ZTIT. T`CL A"'1Y k'�' M p
CONNECT
WORK ADp1TjOT1A.l
O10HOU'SFSEWFR'"
#w..
irm that lam 77 empt ii erT the COnfraCfor 5 LlaenSe
OVERFLOW SEEPAGE %T DRAINFjELD
EXTN , CESSPOOL, DRYWELlI MANHOLE
following reason (Section 7031.5, BVlsnesS and Pro -. ..
ie): -
- - ALTER,REPAIR01 ABANDOtd HOOSE - .... " .. -
SEWER ORD15P0AL S"TSTEM""..':
ry /; D
,i fA '.
ner 9i P p Y Y P Y g as
-
-
L%
le prnpensation, illyda fhe work and the saves
Mended or offered~ fpr saLu
le (Section 7044,'_Business
""'
j I®m-%, .�i'(j - -
fessions Lode")
OWNER'S- Permit E '1C
50
net of the property, am exclusively contracting with
AUTHOYMAY(ON TOTAL FEE -, 2
0:
e: K- q 2 % 5 o t'
f conlractorr5 to construct the project (Secfion„7044,
an Professions Code)
I HAVE AT THIS DATE "'A CONTRA(ST'jn'}P"iHE`HEREIN WAMED CONTRACTOR 70 ,,
CONNECT THE ABOVE'DESCRIBED E'XISiI�G'SVSECL(NG`"`fY)?rwiE DUyBUC"S@}YER
_ 'p c
_p, `� O, —`i 6
°CdgI T,0CT1! rL, R ] 1140 AG'E�M1IC`(i ,v«.,.e�,-..'s.4«..
firm that there s a-wnSTructton lending agency
SIGNED THIS__, _,Z_DAYO
OWNEROR
19
forma nce- of the work for whych this permit .s
OWNERS v
_,
3097 C c)
k e
ADDRESS
dress-- ---
a 1'have .read this_ application and state that the
motion is correct, 1 -agree tocomply with ollCounty
and State laws regulating: 'Plumbing and Sewers,
,r yes of. this County to enter"- -
Boy for mspection purposes.
Pat@72 SEE REVERSE 00R 'E