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HomeMy WebLinkAbout1544A i� -. . �- -�- WORKERS'�COMPENSAiION DECLARATION. - � � . � - I' � LS �I.-hereby aftirm:that I have a certifimie.of �nc9�± r� �oif _ � . . � , -insure,ora-certifimte of�Workers'Compensatwn Insurdnce,or . �annean -. _ � - � � ate��f;ed��{Se� 3������e'Fur�a ��°�e�R1V3,g,; A�PLI�ATIOIV FOR PERI6AIT - Poli[y.No � �ompany -�s � � . � [��Cenified�o�re�,.yfurnished. � � - . SEWER - SE�INAGE DISPOSAL � -' -'�.Certi€ied-copy isf�4ed with.th�coumy b�tlding:inspecteon : COUNTY OF LOS ANGELES BUILDING AND SAFETY ; . - deparimenL . , . oarP_$�2Q�8.�Applicont �'_ Fr�p.l�an FOR APPLICANT TO FILL IN �C��lNECTIC9M�AT� � CEkTIFICATE OF EXEiJ�PTIUN FROM WORKEP,S' - �9u�.mir�� , 5rarioN oeeni ' COMPENSATlON INSURANCE � .cecuess ' _ _ _ `� . : (This soction need noP be completed if fhe work involved by ihe - �� uwNHote aeFeeeNce uvaea _ permit istor.one hundred dollars($100)ar less.) . iocnuTv i�wER NEARESi ) TYPEDFCONNECTION �FNGTNFROM - i certify)hn1 i the performance of ihe work for wfiich this ckoss si. (;! ..i' r. cuze a.�. �M_i.To P.t. �, permit is issued;i shall rtoLemploy any person in any manner - . so as to become sub�ecfi to the Workers'Com ensation Laws ��jT�' t�DE� G+,�ia�.j P.C.Na� �f1 y�a � P � OWNER CO.IMP.NO. JOB NO. ���✓•-d t� Dote P"57�Z11�V�fJdCbeC� ��B�t0�}hP- VdO�kB�S � �yuE55 ���n�. ..._.iEL.1�C�.�_ �j18 � �, � 1 ��AFFIDAyMITN�IVCR EASEMENT RECORDPNSTR ND. �AiE � ' NOTICE TO APPLICANT: �f, after makin th�s Certif cate of i `n� esqtion rovisions.of"he Lacor code, ou must{orthwirh .. �=cnt. j PP i� y DESCR!PTION �UT NO. �,_ HK^!.OR ST.WI�ENING ' �..mply with such provisions or.ihis permii shall be deemed :'. -- �-7 . revakeC�. � -., BLCCK TRACT ��( STATEENCROAGHMENT .. . tJG.OF BLDGS. °EPMIT NO. . . LICENSEDCONTRACTpP,SDECL4RATiON. .' sveoF�or NowoN�ot � i here6y affarm ihat I am!icer�sed�nder provisions of Chapter ��- �U�G oF . ', � 9(�ommenung with Section 7000)of Division 3 af the Busi- � ewtoiN�s ,.,�'1I1� �G� 1(], � cHne�Es - y ness and Frofessions Code,ard my license is in futl farce and.- — — � CONNECTION CHANGE FFF _ effecl. - ey ry : CO!viRACiO"n_T[i}Y'AnhS`.3Y7 (�hT34'�'�" __ _ g.. �' i.iC2n5C PJUm�eI �Q.�'Z�I Lic.CIq55�j'�i�. _ . 'pDDRE55 ya�2� ��e(„'�,(qPO�{�, �S'. REIMBURSEMENT FEE - E}� i; CUn41aLtOI,=� t_rP+eIIlaTl.DOte $12 HfJ � �:T.� �-�.� ���,3 ��.N�. � � � r� DISTRIRNO. GROUP MA? PROCESSEDBV �7 � q1 aK Pc � : ��I am exempt under Set, of tha LA.Co. ' �EN�E No. ��{ � -c nss � F'� ti .: ,: � No. DESCRiPTION OF WORK FEE U �: PlombingCodeandlor5ec � _ofihe —_ -._.--__ - Fir�ni �._, ;: Ha�sE sexce ecNNEerirvc ro 3..7 �}a onrE L(-��. VALI AT10N �, 1 � fVeL,C SEWER �� gn y 8.8 P.Code for the fnllowing reason $EPTI TANK,SEEPAGE P�T OR fi^.Al � '� � � I FlIiS ANC.'OR�RAINFIFiD �� s � aOtB . t yp�SE S-YlER CONNECTING TO �- BY % PR=�4i.�ISr'QSit1.5Y5TEM � 5:. $i9�pYuYC_ „_ CJNNE'1 AOOITIONAt BLOG.OR � � OWNER-BUIiDERDECLARATION � 'wosKTOr+0u5Esewea � OYkkhlOYfSFEPAGfPIT,�ORAlIVF1EL� - I hereby o(firm that I am exenipt from ihe Contractor's Li<ense � Ex7n cec.Poot.DeYWef.L MnrvHOLE . , � Law for ih=_#ollowing reason(Sedon 70315,[3uisness and Pro- aiTea,eErniR os AenrvDON NDusE °I.;�an5 Co(IeJ: � � SEWER Orc Di5PO5Ai SYST"eM _ �4��� - _�'i,as owner of ihe properry,or�ny employa=s wilh wages as - _ � iheir sale compensation,will do?he work and ihe siructure � - .. '� �����' ! l! is not inrended or offered for SOIP.(Section 7044,Business -. y - ond Professions Code). . QV�/�F(t'$ Permit $ �(} Q t c5 ���_�;�; - � U I,os owner of ihe property,am oxdusively contracting with AUTHORIZATION TOTAL FEE 2 p �icenSeC�COniractor5 to consir�ft ihe(JfajeCi($eC�ion 7044,�- I HAVE Ai THIS OATE A CONTRACT WITH THE HER'.IN NAMED CONTRACfOR TO �� � 7 ��" - � 8u5ine55 ano�Profe55ion5 Cotjel. �GONNECT THE ABOVE�ESCRBEO EXISi��NG OWELLING TO THE PUBLIC SEWER � '�. r,h��c;�r; � - CONSTRUCTION LENDING AGENCY l�� u-.. '� � . I hereby qffirm fhat ihere is q �onsiructio� lending aqenty $�GNEDTHIS �� DAV F � 19� � . . ` �- for fhe performance of the work for which Ihis permit �s owrvea oa ���� . . ; � OWNERSAGEM � ._�� - issued(Sec.3097,Civ.C.). � ! - . � .ADDRe55 L:S� R . . .. -� �ender's Name � - - Lender's Address - � -- I certify thai I have reod this appNmtion ond state thoi the: - � - � � above information is correcL�agree fo compiy wifh all County . . � �� _. - - ordinanws and S�ate laws�regulating Plumbing and Sewers, � � - . ` �. � and hereby authorize representatives of this County to enter� � -��- � � � upon fhe obove-menfioned property for inspection purposes ��� � _ ��Or'1��,viCx..- �r--`�-�"�iZ , _ - � Signature of erroittee Date � � . 4EE REVERSE ROR EXPLHHATORY tANGUAGE ;5 _ .. : . . . . ..-- . . --.j��. m DD u�q m D m$ Z 'N^A wv. '^" Z� C �r ZO 3,�`�ro Sr'n a� �Z � �f, �'� mm � C5-s Z^' Q p C � � ' in m Zrn oi =' � � � S� v'D� � D?c �O � m ❑n �� �', zm �v � � D� ,T-nro �C} � 'z � . 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