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HomeMy WebLinkAboutNo Permit Number (5) _ . _ -__ _---- .._._.__ � . _ _ . ___ . _. , __. . _ . . ... _ I WORKERS'COMPENSATION DECLARATION � - ' � I hereby offirm thot�I hove a ce.frficaro of conunt to self . - �I � insore,or a cerlifica�e of Workers'Compenwtion Insuro�ce,or �eae.zo _ . � �� p�eY1N�°�o'��`P����'r`°e.bm`�o'nt-zndemnity � . �,�`°`��B•e° � � � � �APPLICATION FOR PERMIT , _ , "-❑Cenified copy�.�he.ebY+���.stied. . - . - . SEWER - SEWAGE DISPOSAL , - � �:_�. �Carrfied co4y is i�led wi�h the county bu'd�np inspection COUN?Y OF LOS ANGELES BUILDING AND SAfETY • d�4s¢��9�j86 RCR By: Dote Appl�m�t �• FOR APPUCANT TO FILL IN CONNECTION DATA � � CERTIFICATE OF E7CEMPTION FROM WORKERS' �iiq� - � - . - �COMPENSATION WSURANCE� .. �ooxess 1 sunor+ � � � oePrN � � � - - (ihis sec�ion need no�be comple�ed if�he work involved 6y tha i�iiTv lliamond Bar � ��«E��.�cE - � � 1P°`Q permit i�for one hurwlred dollan(5100�or less.) .. �" R •�I certify thm In�rhe performonce of the work for which ihis ceos�ssr. Tr����N��� ' �r+GTHFrtoM .. permi�is iawed,1 fha11 no1 employ ony person in any mannar Y� CURB V.L. M.L.TO P.l. � so oa io bacome subject ro the Worken'Compenso�ion Laws. owr�a �O.IMv,Np, � � ' JOB NO. !O/ ( � Dafe AppliwN � ODRE55 .� Box� 3329 TRUNI(RRMITNp, � � FpAOpERMITNp. � ' ' ��TICE TO APPLICANT; If, afror making Ihif C9�ti{ICOi@ Of ��TY Covina -.,�.818-96/-9541 AFfIDAVIT W/•NEN EASFMENT RECORD.INSiR.NO. DAiE smp�ion, you should�becom8 'subjad �o ihe Workers' i�Ai Compenso�ion provlsiona of�he Labo�code,�yov musl forfhwith � �uR�aic�r� iot .���' Hwv.oa st.wio[wr.� R 2ompiy wi�h such provisioas or this permi�shall�be deamed � �evoked. � . eiocK TRA S7AfE ENCROACHMEM UCENSED CONTRACTORS DECLARATION ceRMir r�o. - SRE OF LOT ON LOT �I hereby a8i�m that I am licensed onder provisia�s oF Chapter � - u�a � 9(commencing with Seclion 7000J af Divisivn 3 of the Busi• g�iipir.�cs n 'gl o1nwc.�s � nea ond Professions Code�nnd my license is in full forca ond . . . . , effect. ' [onr�ciioni cHnac,�r�e 33b428 C..�6 C�NiRAROR �, licenseNu �CI s � 1 s �' �fr-�}-{�jpfg� Qs/�-i-E-f-frFr� ADD4E55 WEIMlURSEMfNT ifE Q v(1V/vv COnilaGtor a. a.aaw. .�te . • DiSTRICT Np. GROUG MnP PPOCESSEO BY V ��,Y � �� gK � z ❑I om exempt under Sec. of the L.A.Co. �I�T��, ��,u O � PlumbingGodeand/orSec. ofihe �� ��R�pfidJOFVJORK ffE F�Nnt � / IqUSE SEWER CpJNECTIPI(:TO . . /� � DATE � �- VALIDATION p�', B.8 P.Code for the following raoson ���A�pyEpq�pT py FMAI � � ? . qi5 ANp/QII pRAINNElO Dale HpUSE SEWFR CONNECiING TO . 8V %tIVAIE 0 Y M $ignOlUfe �'' CONNECi ADDITIpVAI&DG.OR ' ► - � OWNER•BUILDER OECLARATION� W°pK T°�qus�5[v''EQ OYFRFLOW EPAGE MT,DRA�NflEI� � � y�+�Preby offirm�hat 1 am eaempl from the Contractor's Lfcense` exrN.,ctssroot,oarwEu,r.waHo�r ' . . , , . , . � f �for Ihe following reason(SBCbO 7O$�.5,BVISne54 anJ Pl0• ALfEq,REPhIR OR AM.IJDON HOUSf . oa5i0�5 COde�: SEWER OR D�SOOSAI$YSIEM _ - . '❑I,os owner of fhe properfy,or my employaes wi�h woges as � ' �heir sole compensa�ion,will do 1ha work ond ihe structure - � � � , � -� � � � � - . � Is no�in�ended or offered fo�sale(Sedion 7044,Busineu �� . ond Profeaiona Code). OWNER'S Pe�mit S /n � _ ❑I,as owner of the property,om exdusively controcHng wi�h AUTH�RIZATION T�TAI fEE �� (') � � ,/� n licenaed coniraclon b conshucf�he prolett(Section�OM,� � I NAVE AT THIS DATE A CONTRACi WIiH iHE HFREIN NAMFD CONiFI�CiOR i0 � � - ' - r����"O n 'BUSIfIB55 On()PfOfeSSi0�5 COfJl�. � CONNER THE ABpVE DESCRlBED E%ISTiNG DVI(�I�NG TO T/1E tt/BIIC SEWfR. �: CONSTRUCTION LEN�ING AGENCY �'���-'- - ��� �`�. '�� O I here6y aHirm fhat there is a consfrucfion lending agenty S�GNEDTHIS DAYOF 19_ � . � for the performance oF tha work for which this permil is�� �'"�R� � � � ► � � � .. .. � `.+G.7'S� issued(Sec.3097.Civ.C.�. - owNeasn�[rvr , . _ . . nooa[55 _. . t'P�?G 1�Jr�c� Lender's Nome � � - � �� �- � � � Lender's Address � �� � - � � - . , ,, D�.Y���6 I certify ihot I hove read Ihis opplim�ion ond state tha�ihe � . ' - above infwma�ion is corroU.I agrea to comply with all County � � � � � - - - �� ordinanCes ond SMie laws regulating Plum6ing and Sewers, � �� - ond hereby aulhorize represen�a�ivas of this County to enbr � � � � � . .. . -. -. �Vpp(1.16e obo menlioned pro erfy for inspecfio�pwposes. � . 1(I.LC I B3'' �Zi�.�d.�� �• 6/16/86 _ . _ ... Signature�ermilfee Dole SFERfVEI13EFORE%MANATORYIANGUAGE � � �� � � '� �� � , - � � - INSPEQOR'S rtoTes � , OYVNER-$UTLDER DBCLARATION APPROVALS w.re, wsrECTars swwntursc, I hereby effirm that I+tm ezempt from the Contractor'c ����R • .. . . . �,.��.- License Law for the follo�ving reuam(SecHow 7031.5. , . . � . .. . BwiMns axd ProJasiov Cad%Awy dty or cwrwty - eu��o�0n Riw� .. . ..-_ -- . . � -. . � .�� . . �_ . . wbicb'riguirtt o porMtl b c»arh�ts��1tw.�. , � stmC T.�wc,s�v wTis1 . ..� . ��. � . .�.. . . . . � ' aF.ino7u .or n�ir asy ahwetnrs.p�1or b its . ivaoiors ox�irai�w - _ _ . _ also r�qwlnr �appUm�t fo�srdr p�rn.it io Jile a ��� . vsmoo�.❑ -ranveu p . . . . _ . . . .. . ' . . rigwcd stetaw..t rl,ae M 4 Ikrwrd prnwMe ra rbe ' IL1ER.REPAUt 54YIER OR � , . . . _ . . . Prowt�oat oJ tL�C01tbYdOl�l Lta+e�s.Law lCbaptw�9 sw.,cc wsvdsr�srsr�,t . - . � _ fco.rnnewc:ss uritb S�ctiow 70001 9�Dh�ldow 3 0l tbe aa��+rn-r xv�nw � , Susinua a�rd Ay(arior.Cod�J w tbae&[c.swept ,wrt.00n Na,s�sewen _ - wars�»rn a�d ea.aasb Jor r6.au.a.d sr�»ycion.Awy � a�awu m�c T�wcs❑ . . � .. . � . �vrolotioM uJSsctiew 7031.3 by o.y ofipLieaujors p.r,nie ; _ sEe►.�wT ❑ cEssaooa❑ . . .. . . . �_� .. _. __. ..'.':_..��..-.-.- .: : .. .�-.;;:;: _�- sNbjecrsebeappticonrtoaclvJfp�foyoj+rofnwreebmi ....__ ._ . _ ... ..�. .���. ,•�. . Jioc brndrsd dolkvs(1J00�r . . . . . . -j.,,. _ . . ._. .- - _ . � .. . � . _ .�I,actheowcero[thepropertywilldothewo'"�end . ' _ . . � � . ..,... _ 1 ....�. .. .._'__ . _.. . .� . . . . . ...�the structare ic aot tatended or oNered for ale. ,' . . . . . _ � � _. _ ,:. , ./Sec. 7044,Bwi�v wd ProJsuioRr Code:77ii'Cow . . . . �:.. ,. ._ _ . . . _-'.. - .-.._ ... . . .trsewr's Lic�an law doe:wot app7y to a�ow�tr of ___ _. . . _ .._ .. .. __ � . . . . . - Dr'operty wbo brilda or i.Nprot»a fbnros.awd wbo doas �- ' . . ..__. . sucb vrori binat+ lJ proutdd tbM aflcb bwprot�ewb � ; . .. � ars Mot Jal�ndnd or of/end for r�T�.{/,bouHw, ibe � - . _ - ._ . .--- � -- -- -...- - � .build:wg o',ia�proounewt u sold wit6iw owe y�o*of � . _. . . . �,. _-...__.._. .. . . _. .: . . ._ -. .. ". :_ .���• � ' . �. cornpletiou� tbe ourw�bui/d�r u�tll basv tb M.ndew . , � . . . _ . . .....o/.proviRg tbat ba did�ot b�oild or&nproav Jor tb� . ..._ . . . . .: . . . _ .__ .... . ,. .�.-_. . . . .._ � .�prrpose oJsa4r.1 _ .. .. . . .-.- - . .. _ . � . � � � � � ... - . . - ,. .�. � . . .. �I&ih P.][2IIlpt ALaC!$CC. . ---�•� - � -�.._•r..:.. �.� ��.-. ,.. .. .'.. _ . . . . . . _. . ,.�.._.. _ . �, ' B&P.C.for d►ic teason �.,� \ _ _ Date _ _ _ __ Owner INSPEROR'S NOTES . . ..._ _,. .. . :.... . . � . . . . . . . . . �: