Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
1777A
. - WORKERS'COMPENSATION DECLARATION � i iercy c�;rnr�i��c i n�ve a ceriiiicoia�a�-ctsr�>eni i'v seii � �4j. 'nsure,or a certifimte of Workers'Compensation Insumnce,or ��^b°�D II _ '�y,N�PY�s��°f�`�a����b��� CC80R�RF,,,,�3j �►PPLICATION FOR PEttMIT " ❑Certified copy is hereby furnished. .iGWER � SEdIYAGE DISPO�AL � , Q`Certitied copy`is-filed with the coumy bui�di 9 inspection COUNTY OF LOS ANGELES BUIIDiNG AND SAFETY department. � Dote Applimnt � • - ` . - �fOR�APPCICANTTO FILLiN ' -- ''"C4NNECTION`DATA - � CERI{1CAiE-OFEXEMPTIODtfROM WORKERS' ' aunoiN� y+ - COfAPENSATION iNSURANCE�- - � nooaEss � y,pj stanoN oerrH ' This secUon need not be com�letedrf the work`involvettb�-the UPPER � ( P Y ., �«p��TY � AV NHOI.E REfERENCE IOWER permit is for one hundred dollars($100)or less.) ' � t�NGiwF2ork �c �I certify-.fliaf in rhe�performance-ofthe work for�-which�rhis �RpussT., �---- -_ � - _ .,- -rrve_oecoNNea�oni. , . � . .`.Y CURB Pl. M.L.TOP.t. . 2•mif is i;suedl-t shai!nct empl^.y anyR�parscn-.in any mcnner ._ . . v.c.No. so OSTb become subject io-the�Workers.Compensation taws - owvek n co.�Mv.N0. JOB No. � � Ny°'�� Y + TRUNKPFRMIiNO. � - ROADPERMITNO. Dple Applicpnt - A6DRE55 � NOTICE TO APPLICANT: if, after making this Cerfificate Of - � CITY '�' TEL.NO. !FFIDAVIi WAIVER EASEMENi RECOR�.iNSTR.NO. DATE 'vnption, you shovld become subject to ihe Workers' ' � . ii enwtion [ovisions ef ihe labor code, ou must:forthwith tEGnt � P P `/ OGSCRIFiION ��TNO. HWY.ORST.WIDENiNG comp�y with s�ch provisions or ihis permit shall be-deemed revOkCd. � � - BLOIX TRACT Q�� SiATE ENCROACHMENT -� - � LICENSED WNTRHCTORS DECLARATION � - � nio.OF et�Gs. aeanur rvo � . SIZEOFtOT NOWONLQT I hereby a$irm that 1 am ticensed under provisions ot Chapfer use oF - 9(commencing with Section 7000�of�ivision 3 of the Busi- � auuow�s Ct+qRGes ness ond Professions Code,and my license is in full force and EffCCt. j � CONTRARO� CONNECTiON CHARGE FEE � LiCenSe NVmber / Lic.C�a55 � ADDRE55 �REIMEURSEMENi FEE � CO(I}fOCtOl�L �12 al- .. . CITV `�yh¢T TEL.NO. �. q�l`�4:�^( DISTRICr NO. GRIX1P .MAP PNOCESSED 9V � . BK PG ��I am exempt under Sec. of ihe L A.Ca � - u[enEiSe NO. ` 11C� ��� � � � Za ctnss � Plumhing Code and/or Set. of tfie . N�- DESCR!PTION OF WORK rEc fiNAi �j •h10U5E SEWER COUNECiiNG i0 �•7 � onTe..--� VAEIDATION � � - B.8 P.Code for the following feason Puauc sew�e . . SEPTIC TANK.SEEPAGE GIT OR �FlNkI � .IiS ANO/OR pRalNflflO �i � ���e � HOUSE SEWER CONNECTING TO $Y � -PftIYAiE DISPOSAi SYSTEM � �� $ignptUre �� �CONNECr F.G^I=lONk:BIOG.OR ► - OWNER-BUIiDER DECLARATION woR�TONousesewea I hereby affirm that I am exempt from the tontractor's License � �inF�o�uoo�oevw�RA�i.Ninf�Mae Law for the following reason(Secton JO3i.S,BUiS00S5 Ond Pt0- - A.7ER.REPAIR OR ABANDON MOUSE � � � �A���Ode�' SEWER OR OISPOSAlSNSTEM h �'(,os owner of the property,or my employees wifh wqges ps _ � . . their sole compensation,will do the work and ihe structu�e is no�intended or offered for sole(Section 7044,�Business F 9 r��� -. and Professions Code). OWNER'S Permit 3 /tj" gp ❑I,as owner of the property,am exdusively contracting with � 4 AUTHORIZATIOM TOTAL FEE „�'(� �.. g?e o e.e '�fi � licensed contractors to construct the proied(Setlion 7044, - . "i Have ni�ws nnrt n con�rkna wirH rHe r+eaend NnMpo mNrancroe ro � a a�� �,u : - BUSinE55 Ond ProfC55iOnS CO[IE�. .. �CONNEC?TNE ABOVE�JESCRIBE�E%ISTING DWELLING TD THE PUBLIC SEWER. - CONSTRUCTIQN l,ENDING AGENCY � . �. ,� v�;��J`}� I hereby affirm ihqf Ihere is o consir�ction �ending agency SIGNEDTHIS �AYOF 19_ �� for ihe performance of fhe work for which this permit is - owNeaoe �owNeu ncer�r `� 0 Z 2 u°—8�,i issued(Sec 3097,Civ.C.). � - , � . �/��� . aoozess . Lender's Name '�7 �.: -. � �'a�'� 5, iq - � �3 L n er's Address � � � I cer}ify that I have read thi applimti on state that the � � above information is correct.I agree to c mply with aII Counry . � ordinances and State laws regolating Plumbing and Sewers, :. - . and her 6y authorize rep esentotives of this Couny to enter . upon ' above-men� . ` openy for inspection purposes. ' �- « ��� � $ignotur��6fPer�ttee� Dofe � SEEREVFRS£FOREXPtANATORYLANGUAGE � , f� . . �.. w.. .., .M'.a`:kl;q':�,:c Y� }^q�kn� :-I'T�D�f bx"(` Z -:r.:_�. r .+.; 6 . ���ZD7FA �7��v�� �.� � � I � i., � ag�{�'� ,� o��z � L 0 z� m �� �� � � , � �q �*n��b �zi(3� ^ �'� .. � E . ' W O �O ��� Zmi�� .��� . . .... �.. . �� i N .+� ,�y ` ' , ,�. _� , .._.:..�- .n D ny � ,^s Og a�' y ,� i � . . U� �icT_ '��'�q.,`3 . � { I P ` '._. `�—u ����J '� �f'� ��I � I i . ' V , v, i f � � q iJ i � � - i i � � � � I � � � ( � _. _ .._ _._ ` �-- ; �� , I � I ' � z __ ( ; � �� ' i � { m� � _ . .._ �-- — ., i � —. � !, � � � � � � I ' �;, � I _ i � �1 , � ' � �� � _' _ I � � I ��� � , I i � � �� � ; i ' �I - � j '�C � '{ I �� � s �-4J .,�,4n,.�„�i �I , , I' r : li ' � , . .:� .. �..;; �_,,. s:. ., _..�.. ...:�...��:...; � ., ��.:�,;���,.....::.� .. _ .�t ,..,s,T,,. �..,,;.,.,:�,�. .;�. � F � �� �: � � � I ��� � 1 ' � �° . + '� �"' a ,...� ,... ( � ' � . a . S � . �� . ,,. � .9 e I , f � t� � �- � �i I � E � : ' � i ; � i....'.i �'.... �...�. . , � ���- � '., ` ..I. i � � � � . {1 I . � I. - ''' ' . ., I ., ) � � I : � � � �� '�� � � I � '! �' � � '��� � � r � � � 3 l � � . I .'�- � � , . '', . r . �;�� �.� � �� .. . .. � � � �� __ I � . .:j ���.. . � . I � . 1•,; . . . . .. €�ee . . _ °I. , � , . . . ' �1 � a :��� . - t .��°. .I . � � ,. i i: � � { f ii ,� � . . , '� . � � . i � �� � �� �- � � - '� . , �. _ { I' , ^ I , � ;� �� ,, ( .�i �§� .' ' �I.� � � � � I . x. °9'M1 f � . �r I � t � . � jt�o-� i �. . I.� I� . . . � . . i� �� 9 �: � I v i; i � i� i ; , , , „ k i �I .. I j i ;": � i . .. p � �I. i � t- � , I. � � i�� '� 1�� � _ � � i ' ,.I� � i � � � iw ` r. , 1 . , �. ( �I � ' � , ! � ,� ^ ' [, I I, � f ' ( i . � I � � � � f E ( ' � F � � .��._ � �� � i k� � r ,- � , ��. . � � �� - t �:. � � � � ; -� � I� f , ; � I I � � f I ' � , � ; I i � . , � :; . . r ' �� ' � i�.' � '� �,.�� �b���n f°❑�c..ro'� � ��.-� s ��n. � � r�-,o �, . N , � � „ s sa ro� v R �o � 'c? o :: 2 a ".�o c�e � "�, - ,.. .�. . .. � � .. .. � . � � �. !o_p C °ro..ly':O.�::.�.i'�'a��m �1"" q �,., fS'� R -�' ,v =, 4d _ . Fq � � . ,��. ����� 3'fi ��; � n"' � �c � �� ���'� t. a e. � .. 'be � � ro . � b R> � � p ��'o`� � `` " � 0.�, �. � � - ' . � � ��2 �.o � ...�, Z ��-�� ^e�.�.R fi. �± � - . o y e Q " O '� O 'C, °7 iy � ^..� 7� m.. � - � '. (��j . � ��C �.eo .,, `� �p�� � '�Sj h',� � k.0 ^" LD -s ve . .. .._ .. �. � , I , , "'r ^� r.,C <o " �. ;:.C� r' a � � � o h ,,� � .. �"'°' A'C �"C t `�^�A:�0,..,,—� Q .ro S"� O c� �� w.,e . . .. � . i- ' � � 3„�s C 6.� �� ,„ v� � 1� -�J . � �, . _� ' . . .. . �.� LO]. � �'Pv. �p .n R � ' � � •• v: ' � C � .. .. R 'C.�7'.a q � � p.�q . � ' . . . �-. .. � fS� � '�.'V ��,� �"� C3..� � „' A II. `..�'"C3_�p „n„ Q � � l� . . � � � � -. .� - .._. . . . . ... � . e ' � n �.� �� i� p n `e.� 'd.Q-�., � ^`, ;.:.�j_ '��' q R� Po � . . . . � . ,.. � ,.. � �•.p. A��D•�P� � ti ' � ""'w . F �'. .: � .. . . . . I w � y . . . � � �6-�� �:O S:.... �.� .�..� � ,,�, :s a on �.. � °�" ,'"�-. � �., . . ' ' � � � . . .. T II ._. fi � Q „ SS��r.��.� -u�. CC .. � Q � `` w `�°, w.� , .. _ I . A + 'a C^ 'o c '� O .-n `� ' C� 1� , ' Y ��.ti � '.��, O �'O, ,�,ry �-:`'+ '.. �C `.�i 4' � �- � W , ' � . . � ' .. � � . � . �p '„a,o v'fiacy�rn ^W �'�.D��.R �^�n. � t�c�� � .. . I A :: m � rv v _ �° . .?. `� a " � � . . , .- . , - . � . : _ . - j A•p o C'`'� . o q-�'v o'o� ,o �ro° o'� ,, p'" . I ' . .. � � n � �. . . . ' .. � . � i ' . t �. G �..O . a ' „S e .,, 1 �.� � 4 :' ,.v`-1. . 4.,J I E °� ���.. ` ^ � ` �b �: �� : � -,� �� � ..^-, i � " � � � x � y �;y� j.� � � :'° �`.q� _ ' , � , "' � " � �, � - .. .. ° : _`-' a� a.,. � ��.;