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HomeMy WebLinkAbout1445A (8) � - q ��� � WORK�RS'CO�tPENSATION DECLARATION .�_ 76asa2D � . Q_;P P� _�['A.T I�C�N:� FC�R .P.E R M�LT. . : ,.�I . � �� ` ... -. � : :. �. . � . 3 � :' . _.`-- - - - - . _. • - - - -- .-- -'. _ 1 g :� �. ,i "�I herelv-`affirm that i have a`certifieate-of consent�to setf ; . µ•SEW�ER-S_EW A'G-:E DlSP�OSAL ��� k; � �.�nsure.or.n certificate ot Workers Compensatipn Insurance or � � �� �' � ' � � � � `� " ��- - �' � � �a certieied copy thereot{Sec.3800,Lab.C.) � , ,COUNTY OF LOS ANGELES BUtLDING AND SAFETY L�t���;� �� �-Yoli�y-,No. Company ;� �� � ;; FOR APPLICANT TO'.FILL:IN CONNECTION DATA � ��Certifiecicopv is_hereby fucnished. - _ ��� ' HUILDiNG � - � { STATION � DEPTM � .��Certified cop}�i�'S�tedwith'YhecountyTbuttdin�'inspection '� AooRess���°�j�'��� ir,."��� 1J�� j�.;,,y, IZ. YPPER ' �c -� =--tEC[)efCI�e11P. . -' .-:- . :-�.. �. •��. S: A .•� � NIA[titi0it REFERet�-iGE �'� ... '� . LOCALIT i�(-P}-ktv"Y"N-s� F'�'�(,�!d. LOWHR �UdtC _ AppIICLRY - J- �rvEAftES � � � S�'PE OF cOrvNECTIoro i6NGTH FROM CERFIE'ICATEO�`EXEMPTIOV FF20M WORKliItS - ceosssr, i:i-r'�""'•r'�.� 'i-3;?.� 1���y`;'�r, . cuws M.L.TO P.L. « � ..�. COb1PLNSATION=INSURANCE� '��.,' �`�. , p. E "'p"� ;s Y � ?.c.rvo. - - , - � -: OWNER _j J%5 'I'f?..t�Jk l 1t`�.... .x 1 i i%' CO.IMP.NO. JOH NO. m`( p"` MAIL J � ,� ] ' "'`�E71S SCCt70R I1CCfjf'llOt bC completed`�f the WOL�C 11lVO1VEQ ':,ADDRESS y"'t�� ��;�'+x_�� �'�,� - ��� .Et!' ' Sy'j TRVNK P6RMIT NO. ROAO PERMIT NO. � 5 =Uy the pexmft is for une hundred dollazs (�100)or tess) _ p�, , 8� ) y FF,op,,, ,,,�E SFMF �oRo.,�,srR.„ o,,,.E � - � .T .. = .: : � [� CITY�.J.1 e°'it Gi.rt � TEL.ND.,J J � �I tl.�, .��: 9 '-�`certi€y�that ia-iFie�perfarmanc�o£the�wark fai wli�ch thig���-� �e�a� - � - � f-permrt u;;issued 1-sha77 not empin} any person.an:my manner -_ �-aE'sckrPr�oN .-�.�or Ha_ - � Hwv.oe sr.w��erveN� � �� � - "�, � _so as to become suHject 2�the:tNnrker�,G�mpa isatiw�Laws �„�_ k �- - - � - � , a�ocK iRper STATE ENCROACHMENT � �� ._ .. � �/,.s�. �� -. . �--,_. . . . .._ . . . _ . _ . . . _ .. ;eRMt7 wo. ' - ilate -�- �'��pplacant���i z'f.-r�`�. �"iS',�C�va.��G� �, _ . Ud �-N7TiCr TO APPLICA v 1 If,after making_jhts Certifi�ate uf - "zF r3F .ar e. r �_, - . � * � _Ex,e3npzion, �you'��shouY��-becoma s�7>JecE_.-to the:Wu kers ' .use oF _ _ _ cHnxoes �� r� . . _ % a. ._ r "' .. .. .-� BUILDING3 � "- - _- ._.- __—._'____._ '. .'�- _ °-Compensation_proiastonr'af the l,abvr Cbde;:yau must torth .,,�:: — � �� � �- � -- �� � �: � � _ ILIt Ct�iYl�lly \VItFI SkCII Ft0}•j5IQR5,Cit Yllit�GJEI'!lllt SFIAII 1)P. -�;� � F � , } �. CONNECTION CHARGE FEE�- . � -;-ae�medre�oke� _'� --c�carek oa �... tt�-��e S �_ ,,,+^nx�,e..,._� _... ._... _ � . .n .:=_ .�._ _ . -- �' . . . T, �' -LfC}NSt.UC'.UNTHAC:TOIZSDE:CLARATION'�� _���. AODRESS�<' r3%=-' b "'> REEr�nBURSEMErvTF£E � � 3�4 i'a�nct 4r�.e-}.�._ �;.A� � -I hereby affirm that 1 am licensed under provisions of Chaptcr F `-'` s „� ' ` s`o e ---4 (commencing x�i{��Section�700D�of t3ia�s'xon 3 of€rie Busi - �'T�`�'��; a� � -� �.� T�� o.1,�-F y-a-�'°�� � up �TE� �,, �� � = - � - STRTE, - - _LiC. } *j � `�. � =rtesr amEFeofessions-Code,ar�d-my ticense-i�in£u8£orce an� - - = T�r--a �� - �f���--- -' �- � �:-=affecE. - _ _, ucENss c�o. �-� � -ciass -:� :._ . :� t � s -, ; .'_ . � _ . �_ _. T - O OESGRtPTIDN OF WQRK - FEE . - - �o� ro F,nn�_� � �"T -_VALII3AT10N. � �. �-'=Lic2ns�:Vumber -:Lic.CTass '- >�s - _ . .. .. . . . . -nnre�-.. �: ��:�f� -.--' .-'..-- � _.. - .. -. ..p . .. p . .� .. -. _. . .. . �. Contrac[or --l�ate ou J ,ro.. . ._ F1NA}t_.�v �"3a�; .a,� � . ,� sY , �,✓'�..s�� _:=_�I=a3n-cxempt�-:k'rom the�.licensing requirementx ax:.i am a - . _ � _ ���`;�� ; �e .li'censed archstect 'or a�regisTazed.-profess�onaS�;eng ne r�� ° � � ,¢ � _ .ir,ess and Professio�s Code. ..�. '_ �- `r ... .� . .. . � . �.� ^ V ��� (.� q acting in my profess�ona}ca�+ac�tY (Sectiot� 705I Ruv - I9EVER.. . . .... „OVSELE . i.. f:. .. u .. = . „- ^ - . :k:�: � � _- on msro srEm � .�, �.-t'sc=nriteg:.No._ __-.______�-IIate �`.� .. . . . .-� : �.-� �_: ._r.:r_ -.__. -�� �,� ri � -,� .. _._ .._._--- _ ._ _-_ __�_— ' : �.. ._. ._: _ :... _— ._.. :..�.. .._ _..�: �,�:;.e' -` . HOME Ob4'nER-BULI.DER DECLARATION ' - � �' _ ;_ ,, ,,, � dWNEfi`S Fermit --- s °'"�C%,/,1 � ^ 3, .-�I.hereby affirm that I am exempt trom the Conttactorc _ � �License-Law for the fottowin�reason (Section 7031.5, Busi = AUTHOR�ZATEOft� jOfifiL FEE '�'' >'' - � :�. �.�. ..� ���,. a.<,,: ,;_< � -�-nessanefProfessitinsCodej: ' _ .. ... _ . .t.,, .�.. „�o�rR,.�rwr�� - «rfl<oti .:- _ ._.i. ._: - - �,.. � �-i,.as�-ok�ner of':�;the propecty will-do:-tfic work�.:and ths -_ � HE� w wFp aeov E - � ��structure is n��t intended� o uffere�l�for sate_Section ' f� � �� r. ' - t _ 91GNED THlS 3 Y" DAY OF �..i 19�_. ..[ s :- 9044,-Business and ProfessionsCode).•� _ _ .�;� - 6�� � �� � �. �g _ .. ` »--; : _ ., _ _ � .:. owNFRSA�E�r _,�,��.. ✓d'd�. �` N _o �-s-f..: .-- W . .. _... ...: -.. CO?i51'ltUCTION LE.NIII^IG AGrNCY - r : ' �. L ""' ` ess� w d' . . ;Fhereby-affum that.Ehe e ls-a constructlmi le idi g'egc te,y �= �`� - -. ��.k� �'7 it s �� �'for the pertormance of the work for whmh thEs p rm�t �s- � .� �- � =issued.{Sec 3097;(;iv:C) _ ��'�^: _ _ � ¢g. "�' �-��. ��i,ender.'S Name - � � -� .- g r ��������rz �z.^,S �`4 k� �_�,'�'1 n l�,��. � s��. � "`Lender's�Address �� -� . "- ""� �, : ^�� . :., '"*� ' ,. r�I certifyifhat [have`�read this`apPlicatiun<and'sfate that the �'�' � '� ^� � � '"� �� �`� �� � a aa�-�1 �'�(��� � _ ;� �-vabove information is correct.I agtee to comply�n�ith alL('ourty ` ��� ;- ' �' -� �: �; '. -� � � � ��ordy,nanccs and Statg laws regulating-Ntumning�And_Sewcrc,;����� � �T t t �-�^- � � � � '��'"� � � `� Q��'T.'r �'y'' �l. �-. $3� � a+n� �.,�- c � f�-�s �a�� �' ��-.a�� �. sra�3� �.s� � .�',�.. r 5s�.. ��: anda,hereby:authorize;-re resenta[ives oP this Count �-to enter ��+�uPo`n,the above-rtie�riioned pruPertY Coc inspectiw�p ip oaes �.���, �» � ,•�„,"` ` °"`. � .r5' �'`'�` �' '� < �'�F .a�t� ;i�.. f� $. � 3 ,,��.�,-}- �,. `-4. /- f .s - � m.d G E-'.� t St-' � q t �. 3 �y j� �y .k SEE KEVERSE FOR EXPLRNATORY LANUUAG@' � �'�� i ����<'L`-t�F.��_tG^T�� �! �� I�� �,: #� ��, ., . . ;''��a����# � .*r.w s s�. �..�>4.g:3:. ��: '. �'. � �.§ '"�P �' d Sa.� �''�3 § � 3 � 4 A nature of Pecmittae Date `�,z � ��'� � ¢� � �S .� � „ ��� �"'' � F f.�,.. - . � .-�s ,r .�.. .:�..- - - - . ....,�„......a a�,. ...z ,„,n,. _r,w r.. „ . .. . ...��.,.. 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