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HomeMy WebLinkAbout1507AWORKERS' COMPENSATION DECLARATION I heiTeby offirrn that I have aT certificate consent "to se,[,.f - » ,y _of , •, , , , neuro or ceiflflcgte of Workers Compensation Insurance, or ,.-, » ' a certified c the�ve._ro7f (pec 3$00','Lab C) - CE BOB (REV B BI, _ APPRICATION FC1R PE.RMIT ' Poi cy NoKamp.' • Fund „- „ , " I�! furnished. ® � - SEWER - SEWAGE , - D1SPOSAL ce t fled7o(5 eby - Certµfled copy Is filed with the county bullding'inspection COUNTY QF LOS ANGELES '. BUILDING AND SAFETY, , , rt s*y department ,: Da1eF/20,/$.6. Applicant Vx Oa a -n FOR APPLCCANT TO FILL IN - CONNECTION DATA - r R'YfPYCAft OF V,9+(,EI PP7fORf FRzf�wlth )2KE`RS , '. BUnDING -- STATION ....DEPTH~ "" ( '' CON(P SHIIsO LYS I'FM ADDRESS ..UPPER *`(This sect on need nor be completed {the work Involved by tFie MANHOLE REFERENT - - - 'LOWER �?.. `pLrmrf r - - slot one hundred dollars ($100) or less.)'' ... e� +,:.» .. - LOCALITY ,.,. r- ..... NEAREST ".:.. ,,. - ...,.,,, TYPE Or CONNCCTION IEt'fG7fi FROM ,u ,.. ,..«,..,-_.. cert fy that n the performance of the work for which this CROSS ST - - _ . Y. cuas P L c�T -Zr permit 1s Issued 1 shall not employ any pe `son many manner , - - — -• 11 X`"S� as f0 become S ibleCt t0 the :'Yorkers tO 1TTpenSaY On.4aw5 ppT���T� �a--��{{ [[ii T-�j•T+� OWNER t,TRP Co. IMP, NO. ; - JOB NO- ' 1 �" 'z'"`d',Y ,t�;i:/JIM TT - ey - 5�. 329 TRUNKPERMITNO- ROAD PERMIT NO -, Date Appf cantADDRE�E .cTW.A. _ - 1A r,. N d 7NiOTf�CE Tb t'41 �N"f If;' after mak ng'ih is Certificate of, _ rp C�7 C A cm covina ret No 8 �( ,;rV E"9,✓'hl. AFFIDAVIT WAIVER EASEMENT RECORD IN STR NO. DATE -,_ �mption you' sfioutd� become` subjecto the Workers', .- LEGAL pehsation pfp-Vis{oins of the Labor code. you must forthwith fHwv. _,nply with such,. provisions. or this permit shall be deemed "S - DESCRIPTION LOT NO: r� .,. .. ,....: ort ST. WIDENING - - eVOked *h >4a 4I�Eh1$�,,OTfTACiRSDCI.fAi(ON, .. BLOCK TRACT 7 - „.. NC'OR BOWS STATE N ENCROACHMENT _ .- -.. ... M reser q..s. _ -u. z>w , zv v s..., xi ; ..„. ' - ' 1 i�ereby.. affirm that ram licensed under Provisions of Chapter SIZE OF l07 NOW ON LOT USEOF M,F�co m nein with Section of Division 10 of the Bvsl- ( m g i BUILDINGS” - - - CHARGES'- n�3's'dnd P ofesslons Code and my license is full force and '.v }� T�y�T r - - -- CONNECTION CHARGE. FEE e#fact _. CONTRACTOR 1`A- LW,Aip CONST, .r +=�,, £ ~cense NumberLlC Classr�rl'� �,� ._. ... ._ .... ,. .. ...._. REIMBURSEMENT FEE -O 4 S kr j�ry� 1' ��P+)lian 20 86 Date G ADDRESS 4 �' DISTRICT NO .. GROUP MAT' PROCESSED BY Conira<fOr CITY' : oma. TEL NO714-980-W9 B PG * ❑ I am exempt under Sec of the l A Co LICENSE NO. . 47 88 CLASS 7 C34�v Plumbing Code pqd/of Sea he' No eg DESCR1PTfONbF WdR FINAL E- .:' �, P; " ' `P HOUSE SEWER CONNECTING TO PUBLIC sEwER_ �� �O DATE rO �',(p - VALIDATION a- - 6 S Code for the fo1)owing reason ' y < v SEPTIC TANK, SEEPAGE PIT OI?., , "" PTS ANDlORDRAINFIELD FINAL - _ 1 ()at9-•-''"." HOU SEWER CONNECT 11 - BY . 5 .P fI.Q.' �, Ff`"+, .p ,,'T? z PRIVATE DISPOSAL_SYSTEM Signature ._ CWFA ,`B JTf6&, IV "' ^' CONNECTADDIT NAL'BIDG,,-P - WORK TO HOUSE SEWER ® ......F ,.d:. ' ' r i hereby affirm 1hq}. I am @Xemp1 from irte �onifd<)Of S LICen52' _ .- OVERFLOW SEEPAGE PIT DRAINFIELD '.-. EXTN CESSPOOL, DRYwEL4 MANHO Al /'� c' 1 5''ll, 7 I'l Law or the fallowing reason (Sector, 70x1. YJ, ESu iSrtesSand Pro- ALTER REPA R'OR-A- N NOUS - F z dons Code) FEWERbR-DISPOSAC3Y5TEM - g' r. as-ownerof the property, or my employees with wages as • ";, their sole compensation will do the vyo k and 1he'sfrv<ture - I 2 7.5C .:' Is not Intended or offetpi;l fgr sole �Sechon 7044, Business - - -. �j©-. and Professlons.ade') .. • -.OWNER'S Permit $ �..© :a r_' t, 5,0 3_ ❑ as owner of the property, am exclus contracting with AUTHORIZATION TOTAL FEE- Q -. ,ely I license car..,,, OlS to cQnStruct then project (Section 7044, «.,. 1 HAVE AT TH)5 DATE A CONTRAGt WITH TME HEREIN NA1hED CONTRACTOR 70' /� " U V IT BUS nese ¢nd PEOfe55 Ons COd"e) _ . , �.,- -e ✓ UCf"I 1 G CONNECT THE ABOVE DESCRfbEb%STING .. DWECUNGiiJ jFiE P"(1,§L,C,sEWER , »_ - I ,WDINO 1 t " I hereby of{Tim t idf thele Is a construction epd(ng -agency SIGNED THIS O YOF T9_ - OR , -" f for the performance of the work for which this permit is -,- �'si OWN ROR ed (Sec 3097 CIV C) , 'f Lender s TTame ADDRESS- ��¢¢--..' ew„� pv Y'*'TY+c 'E �* '� "�".i' , � ?' Y VR;a:. 9 rv"nvv "„�.t-v .F✓�' -. z �e der s,Adefress - :. w a• s Stat ».� `_ s� �.. , ;; " ,,,... .., .,- ..,.. .,Stat. ... ...,. ., I (certffy`�ihat I have read tha �apphcotlorr and state (hat the .�„»• .,n. ,: »u + , .�, .. .: above information,' s cgrrect I. agree to compN with all'`County' ordLnanceS and S(dt"e`laws�regu lat'ng Plumbing and Sewers," - - - ad`d hereby au"thorize�rep'resentatives of this County to enter 7- - upon the above-mentioned property for inspection purpoossees - - - _ ,SI nature 6fPermttee Ddfe ``5'IYEi%��P'CKN"A"TORV CPNGE)AY,E -, z -