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HomeMy WebLinkAbout1507A (8)WORKERS'COMPENSATION DECLARATION I ha,reby offirrri that I helve aT certificate of copse nt "to self - » ,y , - •, , , , - nsurB or ceiflflcgte of Workers Compensation Insurance, or ,.-, » ' a cernfled c,�P,�,the�ve._ro7f (pec 3$00','Lab C') - �Pol CE BOB (REV B BI, _ APPRICATION FC1R PE.RMiT ' cy No `�.�--e! 1Compgny �i • L1i1C . „- „ y ® , SEWER - SEWAGE D1SPOSAL Ce t fled�0(5 I�! eby furnished.- � - : Certµfied copy is. filed with he county bullding'inspection - COUNTY QF LOS ANGEWE$ ,. BUILDING AND SAFETY, rsar-department ,: ''Da1eF�ZO,/$.6.Apphconr x'PB8le'kYJ FOR APPLCCANTTO FILL IN - CONNECTION DATA - "R'YfPICA1$"�OF��Ey�'('EI��;C^P7fORf FRzf�wlth)2KE`RS ` ;. BUILD ING - - STATION ....DEPTH „"'� ( `''�" COMPErv'V$AIION�INSIgFCF��E" ADDRESS w : , n15 SeCf qn need not be complete cs {the work I�V¢IVed by tfle - MANHOLE REFERENCE UPPER - - - �?.. `permrf - - sior one hundred dollafs ($l Otl) or less.)' .. e� ,:.» ,. - LOCALITY NEAREST ,.:.. .,.. "..... - LOWER w TYPE OK CONNECTION IEtiGTF7FROM ,. certfy that O th�a performance of the work for which this 6R0$s ST - - _ . Y. CURB PL, ML, 0, T+I &, -vpermli 1s Issued I shall not employ any pe `son many manner - - — -• to become Vblect to the :'Yorkers tO mpenSpt On.4aw5 ppT���T� �a--��{{ [[ii T-�j•Tn OWNER ANDEN GRP CO. IMP. NO. ; - JOB NO„ ' aze c '� MAI TT - ey AODREE55 5�. TRUNK PERMIT NO. ROAD PERMIT NO -, Dafe Appf cant .cTW.A. - 1A r,. k drp ,' "ivOTf�E TO f•41 aN"f If, after making' f-is Certificate of, _ C�7 C A crrv, covin ret No 8 �( ,;rV E"�,✓'hl. AFfIbAVIT WAIVER EASEMENT RECORD INSTR NO. DATE "-,_ �mption you» sfioutd� become` subieI& Ito the Workers', .- _ ” LEGAL -.. ".: .•„.... - p sation pro`vision4 of the Labor code;. you must forthwith _ s _,nply with suihprovisions or this permit shah be deemed ^s - oESCRIPTION 'LOT No' r� .,, ...,, `-. HWY. OR ST. WIDENING_' - evoked *h >4a 4I�EN$x�OTfTACi�RSDCI.fvAi(ON'" , ,�k .. BLOCK TRACT 7 - „.. ,: NC'OR BOWS STATE N ENCROACHMENT _ .- ... M reser , A _ ,ie v s..., xi ; ..„. ' - ' 1 i�er&t y.. affirm that t am licensed un der Provisions of Chapter SIZE OF l07 NOW ON LOT USEOF M,F� co m nein with Section'3000 of Division `3 of the Bvsl- 'r ( m 9) BUILDINGS” - - - - CHARGES n�s's'dnd Professions Code and my license is in full force and '.ke#fact }� T�y�T r - - -- CONNECTION CHARGE. FEE _. CONTRACTOR FREMAN CONST, .r +=�,, £ Lcense NumberLlC CIQ55r�rl' �,� ._. ... ._ .... ,. .. ...._. REIMBURSEMENT FEE -O 4 S kr j�ry� 1.st&-A ` Q�G�'V6 1' ��P+)li�� Date G ADDRESS 4 p "' /+� �' DISTRLCT NO .. GROUP MAP- PROCESSED BY - - Conira<fOr CITY' : $ Q�Q�, TEL NO V�� G B PG * ❑ I am exempt under Sec - of the l A Co �: LIIGENSE NO .474887 aAss /v Plumbing Codepgd/of Sea of the NoeE DESCR1PTfONbF WORKFNAL ' p ny �, P; HOUSE SEWER CONNECnhG TO PUBLIC SEWER_ �� �O DATE rO/� //j1_/1 - VALIDATION d- - Code for the fo1)owing reason ' y < v ." SEPTIC TANK, SEEPAGE PIT OI?., PTS AND.OR-DRAINFIELD FINAL _ bate--' '" HOUSE EWE N(ECTTT NG'YO •. .. -. BY z Via PRIVATESA Signature , ._NE•"R r`BJTL^IyED IV CONNECT ADDITIONAL BLDG, - WORK TO HOUSE SEWER ® i hereby affirm that I am exempt from irte �onifd<10f S LICen52' OVERFLOW SEEPAGE PIT DRAINFIELD -. E%TN CESSPOOL, DRYWELI MANHO Al /'� - c' 1 5''ll, 7 I'l Law or the fallOwirlg reason (Sec4on 70x1. YJ, ESuiSrtesSand Pro- ALTER REP/fIR'ORPF11- N HOUs - L z dons Code) ;. SEWER bR-DISPOSAC3YBTEM - ©��01 as'-owner-of the property, or my employees with Wages as • '; their sole compensation,: will da the work and the, sfrvpture, . .' Is riot "'t""ended or offetpIf fgr sole tSechon 7044, Business - - �jO • and;Professrons. ode} OWNER'S Permit $ © 27, 5,0 ❑ as owner of the property, am exctus contracting with AUTHORIZATION TOTAL FEE- Q _ ,ely I license y ContiactorS wto CgnStruct the, project (Sectlan 7044, «.,. 1 HAVE AT THjs DATE A CONTRACT WITH TME HEREIN NA1hED CONTRACTOR TO' /� " � � � � U V IT BUS Hass ¢nd Prgfe55 any Code) _ . , �.,- -e ✓ CONST GC 10) 1 CY CONNECT THE ABOVE DESCRfbEb%STING .. DWELLMGiiJ jFiE l C,SEWER , »_ - r ,WDINO 9G , I hereby of{Timtidf thele Is a corisfrucllonepd4ng -agency SIGNED THIS D YOF 19_ - OWNER OR , - fo„iFie performance of the for which this permit is oWNERs,(„�. - s� ed-(Sec 3097 Civ C). ,g- P 7 ADDRESS- I F ? ��. /' .`� �k i'�' ? � vi � �«3� v'r� Y+c� � 'E�,�* '�s�~� ��* � C�i t �"�".i' �?' Y �.i^4 ��., :. 9 � rv"n "„fit-v� �.F✓�' -. z �e der s,Adc)ress - ” (certlfy`�ihat I have read tha �apphcotlorr and - - - • '. above I,nformat on s correct I. agree io cornpl'y with all'County' - ' ordLnances and Sidt"e`laws�regulaeng Plumbing and Sewers," - - - an`d lTer, a Uthorize�rep'reseotatives of his Gaunty to enter upon the above-mentioned property for inspection ppurpoossees - - fi Vii✓ ®Y - ,Signature fPerm ifee Ddfe ��P'CKN"A"TORV CPNt•ErAYE' m T e 9'Ax:iT•i h`' a " Ma APPROVALS DATE INSPECSORS SIGNATURE NEW HOUSE SEWER -' CONNECT ADDITIONAL „- -' BUILDING OR WORK --' SEPTIC TANK, SEEP PIT(S) 'AND/OR DRAINFIELD - - CESSPOOL: 0..-. DRYWELL li . ALTER, REPAIR, SEWER OR -' SEWAGE DISPOSAL SYSTEM., " ' DISCONNECT PLUG AND ABANDON HOUSE SEWER BACKFILL SEPTIC TANKS O SEEP, PIT Sj ❑ -CESSPOOLS-❑ 1, F