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HomeMy WebLinkAbout1767A � a WORKERS'COMPENSATION DECLARATION � I here6y-�,aff�rm ihal 1 have a�cerhfico�e of consen�to self "7� . g mso�e,oca�ceriificafe of Workers'Compensation Insurance,or �646420 ll �, � t�f co ytker Se la C. - ceuoe�xev.��na; . ������S�om��°° �,�. APPtIC�►TION FOR PERMIT � �_Certifiedtopy.is.hareby.furnished S��E� ' J����S� ��sP���t - � �Cerfified co y'is`filed wtrh'rhe coumy truiid�ng'inspecNon COUNTY OF LOS ANGElES BUILDING AND SAFETY ' S _dep�oJytmen 7 J� - j Do1e.oG/�. S Applicant._�f_��_�Y�}'1___�� FOR APPLICANT TO PILL IN CONNECTION DATA � - � ICER IFICATE OF EXEMPTION fROM WORKERS' �) BUIL�ING �. STATION �EmM 4 , CQMPENSATION MSURANCE a�oxess (�j �4,�r�.¢� � (This sedion need noi be completed if ihe work involved by ihe x+nNHotE r.eFeaeNce UPPER � permit is for one hundred dollars{$100)or less.J �«"Au'� towek � I cerfify ihat in the performance of the work for which this ceossssr. rv�oFmNNpqiON � �NGrHveOH+ -- : ' permit is issued,I shali not employ ony person in any manner . � r. cueB P,i. M.�.To P.�. � so os io betome sub ect to the Woikers'Com ensation I.OwS. P.C.NO. I P pWNF GO.�MG.NO. JOB NO. '�'�� iRUNK pERMit NO. ROA�PERMR NO. Dafe App�iconf ADDRE55 ' NOTICE TO APPLICANT: If, offer makin 1IliS C¢111fiCat2 OF �� AFFIDAVIi WAIVER EA$EMENT RECORD.INSTR.NO. DAiE 4 CITv TEi.NO. �mption, you should become�subject to the Workers �� V ._. _._. --_ . _;ropensot.on provesicr.s of ihe Labor.ode,you must 4orthwith� oescaiaTiau ioT No. Hwr,ors sr.wmeNirv� compiy with:such�provisions or ihis'permil-sfiaA-be deemed levokeC�. - - 5lOCK TRACT STATEENCROACHMENT � M1C7.OF BLDGS PE0.M{T NO. LICENSED CONTRACTORS DECLARATION size oF�ot NOw oN tor I here6y affirm Pha�4 am licensed under pravisions ot Chqpter us[oF - � 9(cpmmencing witn Secfion 7000)of Division 3 of�he Busi- euimwGs i� CNaacEs ness and Professions Code,ond my li<ense is in(olf force o�d � etf2C1. W� �} �CONTRACTOR� . � • CONNECiION CHpRGE FEC License Number �.7 �J�� Lif.[�055� «y�,} �y�/� �/� �^�� Rf;MBt1R5EMEM FEE AD�RE55�—�l�KFT L,rIC--�!1!(�{,�,�.� 'kJ7C�__ _ �._ 9+ COnirqCtor poiB ( ,�t UIStRICtNO. GROUP MAP YROCESSEDBY a' ... / CIiY ( � TEL.40, / � ` 0 �`/ , BK P� .,/y v ❑I om esem 1 unde�5ec. of the L.A.Co. siare uc '�1 , p L�CENSE NO. I�� QA55 �� �� 6 3 i y9�� � Plumbing Code ond/or Sec. ofYhe� No. _DESCRIPTION OP WORK tEE F�NA� ., �t � � MOUSE SEWER CONNECiING TO e� DAiE VALIpATION � - PIIBLiCSEW"cR � P � � B.8 P.Code for tha following reason - � � � SEP'IC TANK,SEEPAGE PIT OR F�NA� p. - .�TS AND/O£ORAINFIECD NJ � Date MOUSE SEWER CONNECTING TO BY - � - VR1VAif D!SPCSAI$YSiEM � Signature CONN�CT ADDIiIONAI BLDG.OR ► OWNER-BUILDER DECIARATtON - woaK ro r+ouse sewee _ . I here6y affirm thm 1 om axempr#rom the Contwcror's License o tErRiF�o 55eEooi okvy'v[uAMari�Hote � - lnw for the following reason(Secton 7031.5,Buisness and Pro- nuee,a¢rnia oz nanNooN House — JOnS CodeJ: . SEN'ER OR GISPOSAl5Y5TEM . - ac,����fl ;_ � Y' ,�'7,as owner of the property,or my employees with wages os �8 B a ` ,� U - their sole compensation,will do ihe work and the structure � - is no�inrended or offered far sale(Sedion 7044,Business - - ond Protess�ons Code). OWNER�$ Permit S � � '�. � a ��7.J�i,i � � ❑-I,as owner of the property,om excl�si�ety com�acri�g with AUTHORIZATION TdTAI FEE Z tj�j e a ,��7_G�J=-- �. Hcensed contr�ctors to construct rhe prolect(Se<tion 7Qdq .i Hnve nr m�s.oah n coNraaa wrtH rHe keaciN Nam�o mNTancroe ro � � � BUSine55 O�GI Pro{CSSionS CO(I2�. CONNFCI THE ABOVE UESCRIBE�fX15i!NG DWELLiNG TO iHE PVBLIC SEWER. n a�r�{2��� - CONSFRUCTION LENDING AGENCY �r c c�� . I hereby affirm fhai ihere �s a construction lending agency SIGNEOTHIS �AYOF 19._ ��� .. ' � for the performance of ihe work for which this permit is . owNEaoR � OWNERS AGENi - . issued(Sea 3097,Civ.C.). J .qDDsesS La�JI-N9��f 7�t�[ �l' �Jp c . . . Lender�Address ,� r���i£( � ( - I certif�thaf 1�have read t is a limti n nd state thot the �� obove information is corraet.t agree io comply wifh alf CooMy -� � ' ordinances and State Iqws regulating Plumbing and Sewers, � . �� ond fiereby authorize repr sentotives of this County to enter - . upon) bove-menfion ro_arty for inspection purposes. � � gno+u�e.��f�ermi.ae � ^� ��A�-��� SiE REVERa"e rC�R bXitANA7�RY iANGUAGE � . . � . . .,r::" .':4'^,�5^�' r+w..m:,:"� Y _,._• V tF�,D'1��� '.Lt yOro�y�� '......._. . ' . . II ��Y7� Z � �f � z = � � ' e � ° . �l�° �rn � `°�,�� ° � f n��m Z �c,r =nicnA. :�Eqr.jaa N �� j � - . � ,- . � � 4 ' d.n�tC��v�, �z����� �_0�� . , �. r� a!"'tl1$�'��: n( r, ':$� - � ., , . . . - , ' ^ .�NDS<.� � m oaixyl '.�� � � rr Z .n t I � � � � - .. _ , �' c � � � + q�� ' � m � �� R � [' �3 ,,k i°�'� � � , � i i �� ', ° � � ° ' �, � '.{ � � � ! s�, � �_-,_ i =,--� � i " � ` ! : ; , � 8 � � � i � I-a Q ;'i ; .; � . 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