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HomeMy WebLinkAbout1547A _ . _ y , _.�, _r �_ _ .. :`WORKfRS""COMPENSATION D�CEARf,1T�01� _- ;�'�'' __ �� - - ` ' - � � . . :r . '. _�� :: m ' __.:: .`. � . .. - . _. ._: - : -=C hereby-�affirm ihaf;1 6ave aS-certificate-of�tonsenY:to se1f,_� ���: - � - - �� _ ,,..-- - � _ � � 5nsure,,or o'certifimfe of Workers'Compensation Insurance,or'":°� '�-�aaaa2o � _. - -= --- -� � ,Jl ��. �; arerlifi�8[opyrhereof(Sec'�38DQLabC,) `� ' . ceaoe�aev-e�ai� ���►p.��ATIQ1�-Ft�R-:RERl.11�f�T - ' �.TTf1n'Z1..^S. +-� ._- � . _:: Polcy..i�iz'r Company. .��`�' .�!}j]�{� _:: . . .. Q4 - _ . .. - _: ... ..__ _.. :_ _ .. - -,; `�- �..{�)�ry ._.., : _�.�._ --SEW�R-.-SgWAG�DISP45AL _ _.u_._ _ . ;: ❑Certifi��f7�i.S P(ereby furnished�. . .. ' . - � . . . . ._. _ .._,. __.'_ ., .. ., . . _ � _, ` i ' '. __ __. . _ � , . . . �:re�rifled mpy is€�ea-w�th the<ounty building inspection ; COUNTYOP LOSANGELES ; --BUILDING-AND`SAFETY . ----_: --_- - depar7meni. . . . '� --� � . ___ Date.�?!l�f?�pli.art ::� �i�PeIDSA FQR APPSICANT AQ FILL IN CONNECTIO►�0 DATA " CER?IPICATE OF EXErAPTION FROM WORKERS' - euaoiNc � /� -� �� �� � CQMPENSAT{ON INSURANCE nooaFss '' � 5�an.oN oEa7H �T � This se<lion need no�be com Ieted if ihe work involved b the pI�O�� B� Ue7ea ( P Y � LOCALITY M4NHOl[REFERENCE LOWER - �_ pe it is for one hundred dollars�$100)or less.) — __ ___.v. :`�-1 certif ihat�in ihe- eriormance ot rhe work�for which ihis � "� NEARFsr �" -irNeoFmuNecuoN t�rvcTHFeou� . Y P CRQSS Si_ '. � a,.�I Y. C11R8 P L. M.L.Tp�.L � permit is issued,i shall noi employ any.person.in any mo ner - P.c.N�. -`so as to become su6jeci to the Workers'Compensatiort Laws - owNea co.iMr.n�o. ioe:vo. L��4 - �`�'�� PQ �4 2 � TR�JNK PERMIi NO. RQAD PERMIT NO. -�-�; >�-Date�____ APP1imN__.—. . naoaess q AFfI�AVIT WAIVER EASEMENT RECORG.INSTR.NO. DATE " NOTICE TO APPLICANT: If, after making this Certificate of ' � ar1 �;Q ret.No. _mpNon, you should becoma wbjec tc ihe- Workers' � . ,f�Ai � � � ;npensai�on provisions of lhe Lobor code,you must forthw�ih ' . oesck��viioh� ior n;e_�_� ,iwv.uu si.vroe�iwc; - ..,mply wi�h such prov�sions ar tnis permit shdll be deemed' � evOYcEd. . - - BLOCK iRACT 7 .STHTE ENCRDACIIMEN? . . r LICENSED CONTRACTORS DEGLARATION No.oF eiocs. °ERM.ii n�o. SIZE OF tOT NOW ON LOT � I hereby affirm ihaf I am iicensed i,nder previsions of Chapfer --- - . 4'commencin �h Section 700� of Bivision 3 of the Busi- - use oF . - _�_ __.___.., - : 1 9 w�t � (SUIlDINC�S �]„�, � n{qQG� '�ness and Professions Code,and my licznse is m full force and -- - - - ,`,`, - -e{{CCt. - ' . �phi.Rq�r.JR CONNE�TION CHAR(;E FE[ �� 474887 �— ���:���nr rn��mT _—__ ___ �' . C34 � r --t�cense Number Lic.Cbss �. nuoREss �'�'Z � �: � p .� R=iMeuRsetneNT Fee � :��� � C011�fqCiO�ms i�T�PP.III'c�Y{ DtliB t)�2�,t Z51'9 _. _ ���y �'�a �Qm�,. iEL.NO. �, $�� ��5?RICTNO. GftOU9 MAP PROCESSEDBY � .� BK PG � a� v I am oxempt under Sec.�. � of ihe t.A.Co � ureniss.No. � a,iss �.� � � "��� �� NO DESCRIPfION OF WORK FEE @J �� Piumbing Code and/or Sac. of the _ ewni ' ! V��O�ATLo�V � ,; HOUSE SEV.'E¢CONNECTING TO DATE ��. P118'iC SEWEn' O �_ '� 8,&P.Code for ihe following reoson «a.ic nuK,srrvace airoa ""'� �'� �� �i��4`p° -- +» �' - Ia1TSqND/pR�RAINFIE.D iWAI � : �_ . Dafe� H<)US 5[W[R CONfvECT,NG TO aY ��'�. ,�r, - f Pftl'vATE DSPOSA!SY TEM ,.� Stynature. ___...—. . �conN Tn�oiiov.a�.su�.;.az I � OWNER-6UfLDER DECLARATiON �woaK,o House s wee � OVERFION SEf�AGE PIT,DRnINfIELD I fiereby affrm ehat I am exem¢t from ihe Contrac+or's iicense - ex�n,.c svocx,oRvweu,nnnNHote �-�T I �, Low 4or the.follow��ig renson(Secfon 7031.5,Buisness and Pro nttca a�vq,q pa n6.�N�oN xoUse - > > ��^,ip�S CO(�2�: - SEWER OR DISPOSAL SYSTEM _ . - �I,¢s owner of fhe property,or my emp4oyees wiih wages as �� _ " n g ��d ��� '� iheir sole compensation,will do the work and the st�ucture � `.y� is nof intended or offered far sale(Section 70A4,Business � . ' and Professions Code). � OWNcR'S Pe�mit g �Q _ ,`... r�r'c= ❑1,as owner of the oroperty,am exclusively mnfracting wifh � AUTHORIZAT�ON TOTAL FEE 'Z'7 5(} � . . iicensed conl�actors to construct ihe project(Section 7044, i NavE qr rtiis ontE A corv��Rncr wiTH rur�+FR�iu NnrtnEo coNrRnrrnH ro �-���-•t��i BuSiness(]nd ProfBS510115 Cod2�. - CON4ECT THE ABOVE DESCR!BEC EXISiING DWE,.LING 10 iHE Pl16LiC SfWEk � . : CONSTRUCTION LENDING AGENCY .� ,�--�- - � i hereby affirm that there is a construction lending agency - SiGNEDTHIS_�.=D�AVpF � 19��. :► � . :�;�� �. for ihe perfarmance of ihe work for which ihis permit is . °�"�ERo2 �..�--���,�.,- OWNERS AGENT ' ��issued(Sea 3Q97,Civ.C). � -- -- nooaEss -- Lender's Name Lender's Address . � � t va � I certify rhat I have read ihis opplication ond state �hat rhe ��� � - obove information is corred.I agree to comply with all County_;.�. � � - ordinances ond Siale laws regulating Plumbing ond Sewers, - - � � and here6y outhorize representotives of ihis Gounty to en�er " � � �- upon the above-mentionwd property tor inspedion purposes ,c_ - - � - -� . -�� r y,; c`��'m�-.;�-�.tl�'��:�-- Siqnature o Permiifee Date � - . 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