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HomeMy WebLinkAbout1231A (6) . ._. __-_: ..._...-._.... .ro�e��o .. __.... _..._._.. . - -... � _ . ._..�_,��._.-___.,. ..... .... .. .., .. ._ . . _. .... . ._. . I � WORKERS'COMVENSATION DECLARATION , � � I hareby offirm that I have a cen�fica�e of consen� to self . � � � � insure,o�o certificote of Workers'Compensation Imurance,o� � ' a�e�,�t,��oPY ftie,eo�,s«:3a�,�ab�.> �E�„��.e,a�, qppLICATION FOR PERMIT PoucyrrrvDQ`�"'--38�fi°^ 'tY . �` , - ❑Cmtified copy is�heraby forniaheA. - - � -� � � . . . . .�SEWER - SEWAGE DISPOSAL _:_ � _, � �]Car�i4ied copy rs flled with the counry bu''d��g inspectio� COUNTY OF LOS ANGELES BUILDING AND SAFETY oaroe�`�g�f$nAPP�,�a�RCR sy:�e�l1,I�.I�}i FORAPPUCANTTOFILLIN ' CONNECTIONDATA . 'CERT�FICATE OF EXEMPf�ON�FROM WORKERS' �i�p�� , - � COMPENSATION INSURANCE� - �ooa[55 24430 F'....Ci0�.C1 oint ��.Place Si�i� o¢PiH � --� � �� � (This section need nof be complefed if the work involved by Ihe 'd[j1OR . ar ' ' M4NMOLE REFE4ENCE ' - ' ��� pe�mit ia for one hundred dollan(ji0p)w leas.) . ��°'OTY � � R I cartify rhm in the�performance of�he work for which rhis Cpp�SgT . , TYPf Of COMNERION . (E�iH FROM Y. � CURB p.L M.L TO Y.L ,' , " permit is iaaued,I sholl not employ any penoa in ony manne�- � so aa to betome subjecl to Ihe Woiken'Compenaotion Laws. Q,Nrv�R Co.iMv,pq. �oe r o.'' ��� /D-a�ie . .. APPlican�- .. . � a,00ecss p.O. LOX �3LJ. . . � TRUNI(PERMIiNO. ROAORRMITNO. . . . ( TICE TO APPIICANi: If, oNer making fhis Certificate of �� ��n.� - �COV 7.A - 6 - nrsionvir WAIVER EASEMENT IlECORD.INSiR.NO. DAiE ,mption, .you should�become subject to �he Workers' " ��ai Compenso�ion provisione of the Labor code,you must forthwifh . - oescaivriori T NO. � ' NWY.OR ST.WIDENING comply wl�h sucFf provisiona or thia permit sholl be deemed � revoked. . � � � � - . �«K ACf STATE ENCROACHNfNT � � � LICENSED CONTRACTORS DKIARATION ei°�s. ffaMiT r�'°. 1 hereby offirm'that I am lica�aed under proviaions of Chapler .. 5izeorior � orr ior .. . 9(commenting wi�h Sec�ion 7000)of Division��cf the Busi• BuimiNns Residential � �„A�5 ness and Professions Code,ond my license b in full force ond� � . effed. -�� � . . coNiknc7oa . } 336428 C-36 CO�N1E I HR FEE , License Numbe� Lia CIP si(�'�7'Q��' � p�p�� � � � REIMBUR Ni FEE Q Con11OC1oIRCR��IN�'e V/1 V I V V . -D�StRI�i Np. GpOUV MAv PRpCE55FD BY V . CITY ' TEl.NO. � _ BK p� Z 3 2ts �uu C-:i6 � � ❑I am eHempf under Sea � � � � � of the L.A.Co. i�N�r.�p. �°C' i7 � � Piumbing Code and/or5ec. of Ihe �� DFSCRIPTIpJ pF WORK f�e ' FiNA� W . . . � ' ��y�q CONHECTING TO . . /� � DATE /4 ,�/li/ VALIDATION d � /' �7� Z. B.8 P.Code for the foilowing reason SEPTIC rANI(, fPA %T OA . ��Np� P�TS AND/pq pRA1ryR[Ip � . . �018 �5(5EW[p CONNEC�ING TO BY . � PRfVAiE I Y �,Signofure - � Corrr�tt aooinoraµ�oG.oe � � ��� '� OWNER-BUILDER DECLARATION �K io�aus[sEwtp � ; - ' Ri�pW 5[EVAG[%T.DR�INf1ElD }''�9raby affirm that I am exempt 6om the Contractor's licensa - ezTM.,c[ssroa.dtrwett MiwHae ' �� �� . .. . � .. � r r�x ! ��.for the following reoson(Setfan 7031.5,BuiSnel3 antJ P!O- PLTER,RFPA�R OR ABI.f.1�ON HOUSF . . � G�^� A �.,sions Code): . sewea oa oisaosµsrsnrn , . . .. ❑I,as owner of Ihe prope�ly,or my employees wilh wages as � �•� � • � O -Iheir sole compenwlion,will do the wo�k and the strutture � � � ��� � . .� •�L 7�5� is not infended or offered for sale(Sectio�7041,Busineu � ; and Professions Code). � --� � �OWNER'$ P9�mit � S Q � -� +�q�•G 7�Jr�c�i ❑I,as owner o(1he properly,am exdusively con�rocting wirh A(�TH�RIZATION T�TAL FEE � � � � - . � ^ licensed conlratfors fo tonstrud 1he PfO�eti($eC�iOn 7044, I HAVE AT THIS DATE A CONiFACT WITN iMF MERFiN NAMfO CONTRAC70R TO � �, Q�C 6-8 6 BUSinlA arKJ PlofeSsionS COtJe�. CONNER THE A80VE DESCRIBED E%ISTI�OW4LLING TO TNE VU&IC SE'NER. � � CONSTRUCTION LENDING AGENCY - �"�� " - � ►` ', - � � I heroby affirm tha�thare is a constroction lendinq agency S�GNEDTHiS DAYOF ro_ '. for the parformance of fhe work for which this permit ia �� °'"'�R°R � ' � � - ' - ' � � ' � - -�� - issued(Sec.3097,Civ.C.). owrv�asac[N* �, . . . . nooe�ss _ . . .. . . lander's Nome ' . Lender's Address -� � � � � � - ' �, � ' � � � � I tertify thot I hava reod this opplication ond sto�e Ihot tbe � '� _ � above informalion is corroct.1 ogroe to comply wilh all COunly . � � ' . , � � � � � ordinantes and Slale laws roguloling Plum6inq and Sewen, - ' ond hereby aothoriza reprosentalives of Ihis County to en�er - � � � - � � , � - ' � � - - - � � u�CR eBoy:e entioned p�operty for inspesl/r�qurp�aps. . _ � �. . , . � _ � . . . _. b 1G/ ti Signofure of Permifl�� Dofe � - . SEE REVE[SE POR E%PLANATORY LANGUAGE � . —__� - � - � �ros�croR's Nores • OWNER-BUILDER DECLARATION APPROVALS onh, iNsvEcrars sicruruRe _.. ,."[h aflirm that 1 m e ' ereb9 ;em?T frum the Cootrsc[oe'a ����a . . . .. . . Licenae Lew 4or c6e folloatns ieamn(S�etio.7031.5. p ,.. � - B+ui�a.r a�d»af.r+�o�r coe.k A.y dry or rno«ey Wn�aN6 o�R woaa��� � .. � .: ... . ... - � . . ..�. �.. . . � wbi[li� Yinj a Jo Cos/Nret.O1tR.br+pnDtu re�9 Pene& . wrKr�mc,sar�r�s�. . . • :- . '; � . ' 'drnioJicb.w it�airr rwy strretrn.prfor m�1tr isrreecr, - iumioaom�iw�€� . . -. __ . " _, ,1r_, . .... _. ...._. ----_.... _ .. .. .. . alto rsquirw tb aypliaatt jo►srtb pnr�it w jtlr a - ��.,--,��- - ��.� � . signsd atateae�t tbat be.4.Aiar�wd¢rrswawt to tbe assrooi�. aerweu❑ -._.. . . -_ .. . '.._. proo:sio.c oJ rb�Coweroctor4 licnrrr Law(Cbopt�r 9 ►�rtR.aev�a,se�+oQ . , � scw�cc onroarx srsr� - .. . . . � ._... -_. (coanaaraq4.wJtb S�etioa.70001��3 oJ Lba , mcorw�a nuc rwo ,• B«sinass ard!'rojaaloar Cod.l or uaar b.1s.x.n+pt t ,waaaa�sev.ez----.. . _: , rlwroJrom m�d tba ban6 Jor rM all�asd szenrydo�.A*y � SFE�v.m sd a�ro�o�s O�.. _.... . . . .__ . ..,,- . '.� ,__� ...,...�- � ... � . �subje�u tbe�tOroaei lp wal�warirnor ee�ba�tt '• ` �._. .�. . � .�, . ,. � Jive brwdred dollars(lS00/.: - - -- I�u the ow�ner of t6e propert�pill do the w�-ti.end , _ .._.. _ ._ . . . � � the atructare�ic nu inteeded or a�f�ed 5or eale: __ i _ _ , , (Svc 7094.Brown a�d PFaJwiow.Cod�:7bs Co�- . . � --.- . . . . - .. . - --� - . . uartor"s.Lieew Lau,doa Mor ypply to as ou»sr oJ . . . ... �. . . . properey wbo brildi or inrOrows tbenow.ard wbo doa , �, . . ... . . " srcb wor�i E�an1,I prouidrd ibai a�eb Impiowm�la . . are eot rwNiwlsd or oJJ'md for sab.I/,bou+ecvr. ebe . . . _� . - - .. . . buildirtg or nwpr»uaw�t o mld wiYbi�or�J�u'of ,:- .._ ,.�.:.� ; ; .. . .- . _ . � .- � . . -- . . cmMpkAiow, t3s oumrnbrild�r will Low tba 6rrd+M . .- -.. . _ . .� . .- -- . �P��*6�t ba did awt brfld or&nproex Jor tJx . . ._ _ __ . .. ._ _.--. _ ....__.. ......� -. . 9arpote of sol�./ ,. . _ . - . . ._ _ ., . - I em ezempt��det Sec.- , . , .. , . , _ , , , . �_, _ • B&P.C.for this reawn • - .\ - - -_ ._.._ __ _ _ ���:..;,.- . - - Date _ Owner � INSPECTOR'S NOTES .� � .. . � . � � . � ��' . '� � � ' � _ � _ .- - --- -- . :"_ ' _-- ' _ t. i — .. , . , ' G��, . ... ,f , r `