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HomeMy WebLinkAbout1546A � � � ; � { ..-, ;.. _ . . �, - —� � �=�.��r 'S� '�C a.�`t �. ��'��`"'�"+�r--.e a�"�. �'�r'� �F°�u �. � ;: (� -'�"�WORKERS'COMPENSATIbNbECLARATI��J�� � .� - - _ = -y,....----� -_ - . r,�" �rv� I here6y offrrm.thot� hove a certifimte of conseni to self `J'�� ' _ -- � _ � . . - - . . I I-� insare,or a cerfifimte�of Workers'Compensation Insurance,pr. . �aaaaso . . . � � � . � 2S a�arf�f�ea�o Ihereot(Sec.3800�+Lob C.) cF eoe latv 8,8;, APPL�CATION FQR PERMIT ', PoI�cY No. - ampany,_�.J�'i3tiG.' �+'LiTI(j. � e�s - _.-_ .. . ... r . -� y3 � _ . . C�1l� p p� �+r t �A �-� _._� � ❑Certifi.e�'d o s Sreby,fum shed �.i :^ . . ` �. .:.. . " ,-561/�ER`'.SCWAVp��J���HL - � _.- . .-. ' �Ce�tifed mpy�s t�led with the co�My bwiqtng i�specr�on COUNTY OELOS ANGELES BUILDING AND SAPf7Y �` 4�; �department. - . ..,'...�_� . - . roare 8l20i�ApplEcam;_�:__���'Iq,�Tl POR APPUCANT TO FitL W CONNECTION DATA � . CERTIFfCATE OF EXElv1PTfON FROM WORKERS' ]�ammiNc � � � � CDMPENSATI6N IN$URANCE. '+ aooaess srnno�v oevrH _..� _. _ - ... F � . � �"- ��:(This section need�no�be-completed.if ihe work invofved by ihe- � ._ i��aLiT� �A� . . ,w,wr+oie aeveueNce oKER � permit is for one hondred do(lars($100)`or less.j �- . � ' NEAREST f T�vE 0�COtiNECTION LENGIH fROM �� -7 certify.that In the performtince of ifie work 4or.w�ich ihis . Ckosssi. '� . (,+"S r. cuxe a.�. nn.i.roei. �i� "permit is�issued,i shoH noi empYoy any person in any manner � ' so_as to become sub�ect io t}ie Workers'Compensation Laws. ��'c �'�t� (i`�Q� ... P.c t�o. y - . _ � ' OWNER o / CO.!MG.NO. _ JOB NO. �(J L-� . � � h�� 'F.')ft.T)(LV. ..r1(] .CJl� 9q f'7�y5�„ fRUNK PERMIiNO, kOAUPFRMIiN�. � Date __ Applicant � � ,: AUoaEss rtt 27f;+s1. G> � AFFl6AVI' WANER EASEMEM1T RECORD IhSiR fvC. D�TE i�. NOTICE TO APPLICANT: If, after.making in�s-Certiticote of ; arv (1QQ_[�,A �te�:No. :rn.,-. -- '*`: .�-^m tion, ou shauld .become�'su6�eci ro�.�the Workers :._��-.- . tE�At _ - - �� - �- � - � � P Y, 4 � � npensation;provisions:of-fiheLa6orcode,you.'must#orthmth . pes�a:airc��u _ totNo. , t+wv.oasiwioetmNc -� �?' -..,mpfy with�such provisions or�his perm�l sha11 be deemed � 2 �^-,!� - . �'- .fEVOI(EO�. - � B�aK iRACi J� j"ry� 5?AiEENCROACHMENT - - LICENSED CONiRAC70RS DECLARATION No.oE eiocs. ��RM'T N° J" . siz�o=�or Noworv�o. i—�— . . p F,' �I hereby affirm ihof I am licensed under provisions of Chopter ��.Gr �k�g.-� �� ��`.� --- = __- — .. 4 -9(commenc'rng with-Section 7000j�ofDivision 3�of�the Bus� -,¢utaiu�s cHqg�Es � �-ness and Professions Code,and my license is in tul;force and�.- yy-��—"—�- � - -- -- - r �:. (� �y�A /e—(�/(f� ��� . � AO�RE55 T�R ����S��l.'j�T�(}(��_�_ REIM8UR110N CHRftGE FEc" ._ y, f ' ..et#ecf. �-7 - COn�c ` - 'License Number�_f_g88�^Lic.Ctass��� �� - ' SEMCNi Fee - ��J- � f �.�, ��O�t�actof 1 s L'3�PiP+�C�p�pQ12 �l���+/e+� _ ('�y T �'] ,( (}q(� qr�(� DISTRICT Np. GRO'uP MAP PROCESSFD 6Y � f - C�7Y- h.10`f�r ,tJOI��- iEl.nO. (�'t'�7-CJW"' `i'G7 BK PG � � ' .❑.1 om exem t under Sec � of the L.4.Co.-: � sTA?e . _ uC � . (`� . P � LICENSE f�m. CLA55 � � NO. DESCRIPTION OF WORK FEE - - t.d ; PlUmk�ino Code and/orSec.� of the� __ Flr�ai � � -` . �iousc sewER coNNEcnN�to�~ Q onre `q,.� q� VA!! ATIOfV � .- PUBIIC SEWER � � � . B.&P.Code for the following reason„_ � sernc raNK.s�e-rnce aa oz F;NA� 8 � PIiS ANplOR DFAiYF1.lD �'` - . , U61E linUSF SEWEN CONNECi1NG i0 �8Y � 4�-_ - - �e � PRIVAiE CISPOSAL SYSiEM _ � � � . $IgndtVre �_- ��. CONNECtAD01T.ON.41.9�.DG.OR +� . � UWNER-BU4LDER��CLARATION week rc Hous s=v�eu � � '� CIVERFL6W SEEGAGE PIT.ORAINFIElb i . - J hereby offirm that I am exempt from�he Cont actor's L cense . exTN.,cEsSPool oevwE0.,MnrvHote $ ; .Law for the following reason(Setton 7031.5 &u sness and P o �� - ��jER oa oi5vo5aie5v5i�N Nouse ��� :,� ,�,���� ,��iy z �,�., .T. s �� , , �;ions Code): - . . .� , ..�. r .. . � � - . , ._ .�� ' _ _ �_� . ` �,"��T.. � a.,SJ!t ��, �^.J�I,as qwner of ihe property,��or my employees with wages os � � . • - ��! their sole mmpensafion,wili do the work and the struciure _. _ - -{'`� �� { (' 'is not intended or offered for sale(Secfion 7044,9osiness� , f and Profess�ons CodeJ. OWNER'S Permit s � � r i, �<<. � �-I,as awner of the properry,am exclusively contrachng wi}h� iAUTHQRIZATIOPd TOTAL FEE 2 5Q �- � - . �� ' . Ii[BIiSBC)-COIIiItlCt0�5 t0 COf15}�UCf 1hP,PIO�ECf(SCCii0I17O44, „ I HA4G Ai iN15 DAtE A-CON'RA!'T WIi4 THk HEREIN NAMEU COhiRA:TOR TO .�'.. f .��.t_.�r.--� �, $USIl1BSS��q�(I PfOfe5410n5 COCIB�. _ „�. CONN�CLJNE AB�VEDESCRIBfO�EXISTIN6-�WEttING-TO-THE'PUBtiC.SFWER' " �� " �� � -� - + �•�' _ �� CONSTRUCTtON LENDIMGAGENCY � � � �,,G . . �"=�'� �%� � ��� I hereby pffirm,,that there is;a co�siroction lending=agercy :• StGNE0.7N15_--S�DAY-OF � � 79..._..; � . � . � E�.' . . .. tl 'CWNER OR .. . . . . for ihe pecfprmanre of the work for'which this perm�t is owNesS r+�erv t9^^�r �^+sG-=✓ issued(Sec.�3097,Gv.C.}. - ADDP.E55 ' t LC11�B(S.NO?16'- ___ � _-. �.� . . ._ ._ __ . __ . . ,. . _ ... ...� .. ::.: .. ._._ . � Lender's�qddress __ _ _. _--� - - �-- --� , I certify fhat I.}�ave read this opplicat.ion-ond state-fhot the ,, - _ f :.above information's corred.'I agree to comply w fh ala Counly���� - . - - - - - - � --- � - � � - � : t �ordinances�and�$tate-laws regulanng Plbmbing'and..SewerS,.. - .� . . . -. `�- . .. - . - - � � F and hereby author�ze�-representahves bf�ihis Counfy to enter- � ' - : -� � � . . .. - - . � - -� "� ,- uponfh/e a6ove-meNfoned pFopertyforinspechon.purposes�. � � � . �, . - � � �.�.� - - -, �µ' S,�:at- . . . -� - . . , - �� _ p �`—��t�AEvr��.�tti—'.. �'—�-3`�� p ��.. 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