Loading...
HomeMy WebLinkAbout1345A (7) � I � WORKERS'COMPENSATION�ECLARATION � - - -. - . � �°#' }� ' I-hereby affirm that I have o ceriificqte nf . �-�Pnt�to self F - � � insure,or o cerlifiwfe of Workgers'Compensotion Insorance,or ��anen20 �. polcy�fNo.co y�-�K�e ��pah��L���i--Lt5--__ '3�Seoaixed.eiatl .. P1PP�L�1/L��►TcIO*A[Id/��-.� FC)tt nE'EcRMIT - u Cerfified copy is hereby f�mrshecl. . � � �SEYrGR � �i�ii7�v� W��f�`lA� � ���; �Certitied copy�s filed wirh the county building inspection i COUNTY OF LOS ANGELES BUILDIkG ANlD SAFETY �, depar ment � � - ._ : oate��Appliconf_�L67 �s���7� y FOR APPLICAPIT TO flLt IN CONNEtT10N DATA > CER FiCATE OF FXEMPTIpN FROM WORKERS' suamNr, �'� - COMPENSATION INSURANCE �� nooaEss �j srarion; `�'f�- ,,;�?� oePTH . �-?�. This section need-noi be com leted if ihe work involved b ihe �J ��` ( p Y � tOCALIiY /J�ANF10tE REfERENCE aO�. , �y'�p . .. permit is for one hundred dollars($100)or less.) �#' NEAREST TYPE OF CONNfCTION IFNGTH FROM �� I certify that in the performance of ihe work for which fhis Ce05557. __ r. � cues et. n4.�.iOP.t. ��J,d' �' ,� - permit is issued,I shall not employ any person in any manner �' . - � = "�` N.c No, so as to become subject to the Workers'Compensation Lows. � ONNER - m.innv.No. ioe Na �'�.�'� ° �'�, � . 4 �IL TFUNKff.RMIiNO. ROAOPERN�ITNO. _ � Date Applimnt 1 nookEsS . � ' "' AFfIDAVii WAIV:& EASEMENT RECORC.INSiR.NO. DATE ���y�, NOTIC't TO APPLICANT: If, afier making this Certificate of , ,- ��TY �. TEi rdp. „. �,` _ ' � Exemption, you should 6emme subject ro 1he Workers' . �wA� _, � ,.r` Compensafion provisions of ihe Lohor mde,you must forinwiih .- `c aESCeivrioN �oi No. � r t7�' Hwv.oe;T.wioENMG - =�^ tomply wi4h such provisions or this permit sholl be deemed '�"' Y2VOIC2d. '� BIOCK 1RACi ' � ' STATEENCRQACHMENT- � � MG.Of 6LGG5. PERf.nl?NO. 9 LICENSEDCONTRACTORSD€CiARATION ' szeo�ior - n�owoNioT � � • 1-hereb a`f�rm ihaf I am 4icensed undar roaisions of Cha ter —�� � Y A P ����F oF .�.. .�:,�L%�� .,!'O 5�'� 9 tcomrnenang witn Sedian 7(�O)of Urvisiun 3 of ihe 8usi- emio�Ncs_ �- �c�`�pyyz "� ana�es . ness and Professlons Code,ond my license is in full force and - - —'— — — @fFBCt. ^y+ y,,�,� ��CON4RACTOR ' � - �. � CONNECTION CHFRGE FEE LiCenSeNum1ber �fl..3 C 5' LiC.CIasS � - � ADDRE55 ? r r ;��' �` ftEIMBURSEMENTPEE COYIhOC10� //l�g���y C`3/�ifDpYG'_______� .��CITY h .._�FL.NO. �I4['� "i� ��ISiRiCI NO. CROl1P MAP CROCC$$[0 8Y �� �a l �p` — s� BKp PG ���"�^""^"` ❑I am exempt uncier Sec of the LA.Co. _ . � tiCENsc No J q J�C�, c ass �y- ¢(j �� „�!j ,,,g� NO. OFSCRIPTION OF WORK FEE -�� — Plumbing Code and%or Sec ___of the .— .�iNn�_ PBLSC SEWER CONNECi1NG TO �El DAIE VALIDATION ,{,� .B.&P.Code for the following reason . - sePi�c raNK,SeeanG=v:i oe j �� � i�.rs nr��roe QeniuFie.o_ � FiNn� / �_ Ddt2 � HOUSESCWFHCONNF{_iNGTO BY � .P2NAtE�ISPOSAt SVSTEM � � �S191YOtUrB_ _ � (S>NNECT ADOlilO'VAL BLDG.OR ► � OWN[R-BUILDtR DECLARAYION � � `NoaK Tu Ho�SE sEwEp _yi�.- � OVERiLOV�``EEFA6E P'T,DRAINFIElO. I hereoy affirm that I am exempt from ihe Coniractor's License ex?v..ces_Pooi,oenveu_n4nnHu�e � � L�w for fhe foflowing reason(Secton 7037.5,BWsness ond Pro- a�reu;uevnie oa naqNooN iiousE fessions Code): - . se�,veK oe o.scc'sa:_svsr�M �� � ❑I,as owner of ihe oroperty,or my employees with wages as � _- . . �1 v�5� fheir sole compensation,will do fhe worx and tfie struclure � . . . is not iniended or offered for snle�Secfion 7044,8usiness . � - � � � and Professions Code). OWNER'S P2rmit 5 ,3 r_'� � - �`+ � • • 1 � ❑I,as owner of ihe properfy,am exdusively coniraciing with � AUYNORIZATION TQTAL FEE �� � w t 2��S�.. - licensed contrcacbrs to wnsiruct the project(Secfion 7044, . �� i HAVE aT rHis onre n coureaci wirH-He Neae�N r�anneo coNrRacroa ro -BU5ine5S ont�PlofeS5ian5 Code�. � CONNECT iHE AenVE DESCRIBED E%ISi1NG OWE�LING TO iHE PUBLIC SEWER a o n(,'G/��� . CONSiRUCTION LENDING AGENCY - �- -� , G J V SIGNE�THIS DAYOP 19, ,� _ rl - . � I hereby affirm thm ihere is a construction lending agency � ��L�� "��1 - � � for the performance of ihe work for wh�ch thls permit is - °�^'""-�oR � _ - owN�es nceKi � issued(Sec 3047,Civ.C1.). J � , . . Lender's Name�q�[��q.L-?1"fi�L-I . -�J�ij'}_�/�,_,)__ - aooeess ____ . ' - Lender's Address_�.t�j�_S_ ZA �j}('r1.��L�.81�4 �?„;,��, �j��-� � � I certify ihat I have read this application a d stat thai the� � � .,j above informaYc is correct.I uyree fo wmply with ali Counfy � - - _ � ordinoncas and t te laws regulafing Plumbing and Sewers, - � �� - ❑nd he aut r�ze representaiives of this Counfy to enter � � upon e d property for i soecfion purposes. � - �-:„1 / Signatu�nf Per_�„� _-� Dcfe o«.cv'ea>'e F�+R eXrLANATORY�wN4UnG� . . . . . F�. . . .�., .. . .,. -� ., �� �� m; ^ n�' co Z _,� F an �' 4� o� -z z . . I .. . , . ; o�' m'� O p�y "Z s . cn en Z� o`o � D �-ni c �S !1 ,TD oZ 0�� rcr.'�, '� '0� J.1 N ❑ J+'_ rU0 . 1. . �._ Uv o �' � v .. . . � n C .�� 7m 2 s �� � �.. .... C �nm � n� � Dm - O- - _.. . �� R';u p0 � � ... 1 . .. v:.. ... . .. �� uQ �Q � �ON '�J �y. �ri �� � � I � .. . . . �i�J' � ' ��'��. N � ��' . 1 � � � V i � 1 1 � i-, ( 'j i I � � , � ' � ,-�-- I � I � D, � i� � .. � . 1 � . sa': I � � 1 � :, I � j � � � N i � , ; � _ l � ; � , � ; _ � I . 3 I V ' .. _ . .. , A1 � N i. � f^� I , i c� Ii � ; ► �� , � � j � � �� � � _ Ii i � � � � i I � , I ; : , _ .� l � � ; + -�,. I ; � � �� , , _ ' � - �� �� , �� � 1 � i - � � ! � � � 1 j � �i � � I { ' � � i � � ; � j ! ; � , � �. � , I � I � , ii , � � , . ' � ' : � � � � ss � 1 � . � � I , � � � , � � } , ; ', 1 � I ; i � � I E � � � .� 1 I i � � � � � I �, �.�-�. �, a ti -�..» �-: 0.� Ca,..� -' . . . � . . . �. , ..- ��.°o �cn � o p � r�❑a a o m�� o�.6-<. �� 9.� . .�i � � n . . _ .. � . - �'j� �j ;� . � b''�-,tr,z,S A�� ..�� � � ��n� � � q .. �� ,� s� � � � . �J F'". � � �•g'O s � ^4 V Pa � ,�.C q � h q 4 �M „ � � � � '�i C� t� C � �..� .p . � � �. � � .u � , � �-. ,� .. ?A � � 'S5 "t',� `°� � � �� ��� ""�'`� mro �`�.a �.� ° w n �� : � �, � . �'� �`' '^ `0 c.r o � ra Q �-�. .n� sc�� K a. a � C� (� ��'�'� �,. ' 'r.z `.��,`" ,� Q� n �'"�.p �� m w � `a� s I ro, � � �o � � � ,n .� s m '�. �s � �` '� t� n o � �k �"o a � ��, i��y ,� � `e A � �, �'�7 P -r m ,��, �',,� I �r, . � � o �' :> c � � �. v�a � � �� ' � k-^°� �. 5 Q+ 41�•�'� �`�re �'��.'A-�. 7 � �53 ��-� 41 � � ; _ ."$ � Q��, � ���'� ;� re �� . - � �, v m �.•p,cJ i �y ;s .� y � �� � . r,q I .(� . O (6 ,a'4? � �l6 ,.�. (1 41 N S Q t s'�.' . . . . ' �� C� 47 � A y A..., n �. ,� 'z,q '. ..�..C'o �.. �.�;- � .� a ,� p�q . � � � � � �+ � '�t S,n "�� � ``� �' a�+ ^�',Cv c,a � � �'�o � : � � � h � .m w m � u ., �� a.,� �, �.* ? �,'� � x � t C') � o ^u� q� -'�'� ° h � :�.�w � `°,�; ��� � �� �a. � �I. 'S n 20 `c.' � � �„�b � O _ �' y��j . . . . - I � �C ��'=n`�s�.Y n� �a.'n' �.�+,h a ,.° I�� A_ ? w.a,'T.' °- - �ly �0 '3 `�.�„p ,. �S� � w,F'n ^�+ w � c' M +a p'i„ � o �� AAc� ��,, t � o"`' t� "� ��� ot"i � � �'m �^" �o P t e � ;,� ' C1� � � ° �' rt � m m r � � b � � � Q o' �A e " ;; ., � � . ^ � - ��m Y s s ac � n �w �'��', `�.� e r s� v � w�n � ^ a� T��>- � �: � '� � f"On v � �K 2 Q� h �.. -.. , w .,. r. . . . ... . . ....._ . ... .. . . :_,�,5 tG 9 5'� R ,O � �' � i" "'`�, �" `�' �� �" '`-2� . .. .,..q :......:....... -' . [J e`t�h N •�• y "a. '2 c. m b t0 P. . `C:'. .._....