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HomeMy WebLinkAbout1766A .. —�--...,��..ao-wmrrnaNnvrv UECLARA716N � � � I hereby,affirm ihm I have a c tif cate of consenr to salf � . � nsure,ora ceriificate�of Workers'r �e^sot�on:na���o�ce,ar ��^�4'� � '� _ � o, No��vIE P�on800 t���� �d�U aE��,B3; APFLiCATfON FOR PERMlT ,� SEW�R - ��WA�E DlSPOSAL ❑Certified mpy is herehy furnished.. ; ❑Certified�opy�s filed w�th ihe counry building inspecrron . GOUNTY OF LOS ANGELES BUILDfNG�AND SAfETY - � depariment. Date .4ppiicanr_ FOR APPLICANT TO P�LL IN CONNECTION DATA CERTIFICA7E OF EXEMPTION FROM WORKERS'. a�n�iN� COMPENSATION MSURANCE � � nooaess 1 ��j , STnrioN oE�rN (This seciion need not 6e completed if ihe work invoived 6y the MpNHOIE REFERENCE VVPER LOCALIiY LOWER permif is for one hundred dollors($700)or less.) - t�NGrH peoM � I certify thot in the performance of the work for which this NEARES� rvveoFcoaNeciioN _ CROSS ST. Y CURe P.l. M.l TO P.l. permif i5 i55oed,i sholl not emplay ony person in ony manner , p.G No. $$$ so as to become subject m rhe Workers'Comoensotion l�ws. owNea co.�nnP.No. �oa No. �'�� � ,y��� TRUNK P'cRMIT NO. ROAD PERNJi NO. � Dare__�AppNcant � rooaess �t""" AFFIDAVIF WAIVER EASEI.IEM RECOR�.INSTR.NO. DASE . NOTICE O A PLICANT If, ofier.making �his Certificate of arv rei.NO. �- (�'�_q,�'� � �;mption, you should bemme.subjeU to�the Workers' iE�pi , � � -spensatio�provisions of the tabor code,you musi forthwith �esta!nrior. iorvo. �j Hwv.oasi.w+oewN� � comply with r�ch provisions or tnis permit shali be deemed � � - . �CVOke({. � BIOCK iRACi 7 STATE ENCROACHMEM � NO-OF BLOGS. PERMti NO. IICENSEDCONiRACTORSDECLARATION . sizeoFiot NowoNior � i here6y offirm that I am licensed under provisions of Chapter �E oe 4(wmme,ncing with Se<tion 700�)of�ivision 3 ot the Busi- suuoiNGS �` �G11+.- CNqRGes � ness and Professions Code,and my license is in foil force ond - effect. r�f� �q coritancreR 'S - cOr+uec*ioN[rsnac�Fee - Li<enseNumpber /JfI'JfJ�✓ LiC.CIa55 � ADDRESS (� �� -REIMBVIiSEMENTfEF � ' � COniroCtOl[�t�. �I ' DOfe 2 Z7 � ' �} TEL.NO. � "-��J�—�a�f D�SiRICTNO. GROVP MAP PROCESSfOBY � :� . GITY BK PG - � STnrE uC. /� �pE ❑1 am exempt under Sec. o{ihe L.A.Co. . uceNSE No. . f,;s tj an55 � L - � PlumbingCodeand/orSec. oftha � No. �ESCRIPT�ONOFWORK ffE FlNA� � � � . HGUSE SEWER CONNECTING TO pATE VALIDATION � Vw PUeUC SEWER � 8.8 P.Cade for fbe following reason gPTi�rqNK,seevnce vrt oa � � - � PITS AND/OR DRAINFIELD F�NA4 �� ' DOtB -.10U$E SEWER CONNECiING TO HY � � PRIVATE DIS?OSAI.SY57EM $i9nqtUrE ^ONN�Ci AfiDiilONAlOLDG.OR .► ' OWNER-8LlII.DER DECLARA71pM wOkK io�ouse 5€y�[a �- �hereby offirm that I am ezempt from ihe Contractor's License o tNFio��Lcp�Ywoea�nivNoie -� � Law for the following reason(Secton 7D31.5,Buisness ond Pro- auea,aevA�u oa nennDOrv HouSE .. -. � iQnS COC{f�: SEWER OR DISPOSAL SYSiF,M _ �.y�,as owner of the property,or my employees wifh wages as . their sole mmpensarian,will do the work and the structure �� '7(�(�R is not intended or otfered for sale(Section 7044,Business - .. ond Professions Code). OWNER�$ Permit S ��a ;� �i e s a a l � �� - ❑-I,as owner of the property,am exdusive{y contracting with AUTHORIZATION TOTAL fEf . licensed mniractors to consiruct ihe projecf(Section 7044, i HqyF ar rws oatE n coN*RAcr wRH rHe r+eaEiN rurneo cONraacrOR To � � � °2��J Lr,7 BUSifiCSS anfJ PfD{CSSionS COdCJ. - �CONNECT THE ABOVE DESCRIBED EXISiING�N'ELtING TO iHE PUBtIC SEWER. . � CONSTRUCTION LENDING AGENCY - � "�' "�P�I j(;� - I hereby offirm thal ihere is a consiruction lending agency SIGNED'HIS DAYOf i9 ���� �4 - for the performance of the work for which this permi! is owNewok � ��` R— OWNERS AGENi issued(Sec.3099,Civ.C.) �`�/ ApDRESS Lender's Name `-�!!9'IM�"/1���1. ��. Lender'S�A�es� � �d�,n��r �6�{O(,� . .. �cetlify ihaf 1 have read' is opplicati6n 6 d state ihaf the .. above informofion is correct.1 ogree id�omply with all County - . ordinances and-$faPe I ws regulating Plombing and Sewers, � - � � ---- - � ond hereby.authorize presenlmives of this Cooniy fo enter .-. - � � � � - -- -up e-above-menti � cLyrpperty for inspecfion purposes. _ '-, . �. . . . . . .. : .::. - . ✓����c'���•�,, ��. . - . Signatue.bfPermiitey" Date � : . �. �� SEf-REVERSEFQR�EPiANATQ?Y:ANG�AGi ✓/� � __ " -.. . . � � , . � . ,.. _ . . * . �;�-'b�:o n :� ��„ C� z ..: . .. . � . . � ��, ,. o ft��Q� �� .'O 4��z�� O. . I... I . . . . i - . . ..., �"Z� i- '�A G7-� C ��� � � - � - . - . t < Z �L� Ci� { i Is�� D m og� ;�, { . � � �": p . . . �. �� � �� � O �y� j �... . ., ���C � Z �`G� <� �'� 9 �;� �' i�p ' �� f � i . ' _ . � 4 S . , . . ���mZ�lx� p �d Z� p �"qW�, � i � Q � � � tl . � , . t {...r i� � . ". ' . , 'J�..'d'z.�;'�am"�.�:m � i � e�"� . � i i. 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