Loading...
HomeMy WebLinkAbout1162A � ' WURKERS COMNt',NSATION:.DECI,AR.ATION . 76A642D � �E8o8,2So, APPLICATION FOR PERMIT � nerenv aff�m tha, , ,,„ve a cer[ficate of consent to self SEW ER-SEVI6AGE DISPOSAL � ��� insurc,o�e cex[ifirate ot Workers'Compe��sation Insura e�,or �� a certified copy thereof(Sec.3800,-La .C.) CUUNTY OF LOS ANGELES � � BUILDING AND SAFETY �i�, Policy� �{��'p�nY "�. . f�',❑ Ceiti£ie—d�o�ereby fum�shed. FOR APPLICANT TO FI IN CONNECTION DATA Bp����SG STATION /, DEPTH ��-� Cectlfied copy�is fiLed wi[h the count b 'Ulin � o�E s ^� � � r � "' ���`"' u �� Y g i � ect� n %=�' depart ent. /' i � � MANXOLE REF'ERENCE �/� /� � I,'.Date � C' .&�pplicant�r����s��1j�6e�1��'/Z� �o �ir r�. �ZG-J c��s y-. .�7� �rY% �E°� oweR �(. NE ES TVPE OF'CONNECT LENGTH FROM j � �'��, C E T I F I C A7'E O F E X L M P'[7[O N FROM WORKF.RS' � ° - _ m.�.ro a.�. �,�2 _� , .A.. COMPENSA'f[ON 1NSURANCf: 55 Y v.c.rvo. . WNER �/' i/�.�l-G-- CO.IM .�a i '�'�(This section need not be completed if thz wock involved ADORE55 UNKPPERMiT N .�, , t • • TR o Rono Pewmi-r rvo �-��by the petmit �s for une hundted dollazs (SI00)ox less.) �'� � „F�,o,,,,,,. „,,,�t„ E„st,,,E«,RE�oRo.��,rR „o o„rE a � �1��• O ,��I certify that in the perform�nce of the work for which this t c,T �w� � � y��2 . � . 3i p�rmi[is�ssued,1 shall no[employ any person�n any a ner � eeseaiPr�ow �or Ho. / �'so�as to be nm subjecY to t:Ye�4otk2rs C�ipe 3.io ws r� �]" f[[� wwv.oa s•r wioeru�Nc � � �� � / HLOCK TRACT .�E��'(IJ�..7 STATE ENCROACMMENT f... Da[e - ji' Applicant � 7✓ ��� Nu oF e�oc, �ERM�T NO � � �OY NOW ON LOT 5 Id} ��'�70TIC T. APPLICANT:If,af er making this Certificate of ' size oF � �.Exemption, you shout�3 become subject to the Workers '! use oF �. eu�Loirv6s -Compeasation provisionx of the Labor Code,you must forfh _ � 1 _ � "GEs � � �wi[h comply with such provisions ur this permit sL�ll be COrvYR0.CT0 . � ^" CONNECT�ON CXnRGE Feea ��,;deemed revoked. - .%�� .- '�=—^"� � ��'. � � rzE1MBlIRSEMENT FEE �. LTCENSEU CONTRACTORS DECLARATION oeess , � - „ j�,f-, . "�-I hereLy affirm that I am licensed under p�v�sions of Chapter AD J �', EL.N � -/�� ?�. 'Ta°T"' °ROt+" maP Pao�EssEo a. ��`9 (commencing�nth Section 7000)of Oiv�s an 3 of the I3us� � °1 J a" "�. 0 0. �..ness and Professions Codr.,artd�my!c s,�s=m�full force'and i-srare - � ;p� .A /� �9- � �effect. � � , ��� C �, � : � �iceHse na:� � c� ! ➢C� /" .J �.C-s1-4," .. � . � ti' NO OESCRIPTION OF WORK FEEAS "' y* :� � .. . ._ . i�Nc'ro i � F'�"� VALIDATION "�License.Numb -��/� Lic.Class ti"i�/� �y� F 1t[1 -�owTe � � �� �a` �P � �Contractor ��Data�C'��f ? ��� �� , � �q, � FINAL, �' rv '#. . � *A c BY �>`J.. �� . . r �� I am exempt from the licensing reqmrements as I am a �„� G.oR -- " i�'�L_ � lieensed xrchitect o a cegistared professional engineer y„�;,� ��r _ 'j acting in my professional capacity (Sectinr. 7057, Bus (,� � ineas aud Profesaions Code). �' � � � �'Lic.or Reg.No. �ate �p' oosE . � �� ._ � . . __ x�� ' , __ ��;. HOME 014NER-BUSLD�R DGCLARATION_ .� � . . , �s *I hereby affirm that i am exempt from the Con[ractors ���� �WNER�$ Permit f �� - ��License Law fvr the following reaaon (Section 703t.5, Busi �-AUTHORIZATION TOTAL FEE :�p�� �� � b,'�{� ness and Yrofessions Cude): ��� �� � � � r«avc wr r�is o.rE e N #• •'• •,� O ',� I, as owner of the proCerty,will do tkie work and tlte �, ro rHE P�n��c T T"`we vc uEs�«�aco E�i`s E��N� . �3 structure is not m[ended or offered fur sale (Section � SIGNEO THIS�.�__o X oF oWiy `�' '� • �2 2,5� �� 7D44,Business and Prnfessions Code). �J �6 (' ±, N ` � � �� a � A��/ll � � � �.%-1�rr.��_----- . . = i �,� CONS7RUCTION LENDING AGENCY ;�'A � � , 2 Z�J.O U �.;;1 hereby affirm that tiiere is a unstruction lending agency ��? - � �(foc the pecCormnn�e of the work for whieh this permit is � �Z 3�-8;1 :tissued(Soc.3097,Civ C). q d`;Lender's Name ::�i: � � �i --��Lendcr's Address � Et��-I rertify Ihat I hnve read This application and state tha[th � �� .�inbove inforntatron is correct.1 agree to uu�nuly with all Cnur,ty � <f:ordinances and S[ate laws regul:�[ing Plumbing and Sewers and liereby nuthorize representati s f thi5 Cou��ty tu enter �'�'. �upon the abov�-m ion, pro rtv or�nspection pur�oses. '� . , � ,j ?� y�—' SEhI REVERSE M'OK EXPLANATORY LANGUAGE � � /.f�!-����d.a'G' . nature of Permittee Date � +3 .f. : � 2 �fi`���� t� Z o' -Z\ Nm va m� �u� �``�����m���� p-o R��,�`��vm�o, ���.�,z�.��m -o � Zo�c��\ �' � �, a2 ,,my� �'�Z'opO�m O � �r °m;�v.fl �. �.� G inN sa �D p '�i,nOO\� �N� om� °c�•°� �<_ �fib��2 \ : � �-� m�;r m � _��o q c'��n N�' �,cnz\m �t � - -a� �f�`, ... . . � c�T> :-�(�\ iP � - o➢Z m� ;fi4,�a d .._ e�--..3 �N\"� �� 7�a ��. �a ��` m .� � .' z .p q � ',� � _`�3 ��� � ` � \ � � .. � u-:- � p..,,, t,. 2� ;;, �,`"-� '� �,�'., � � �i ��i, C�� - ��, , ,c_. �� p m .y..., -� N � `�;' '". ; 2 ` t0 Qa �"w. � � ��� �'� � M ""ad �� � �� � N ,c , , rya . � N ,__.._ �C7 �' � \ � "� �1� �..� � , � � , ; \ � � �` \ � ,t �. � ` � . ,,, , , ; �� � � ` � � � � � �� �� ��� � „ � � � ����y� � �� � �� e ro w � Q at \� q7 n C"�j�'� O x m� ry'u -�L � ' \ t \ ^'� O m� '�� S� m N 'n '^ C`"'� .�' . . � . .�..: '� � \ � � � � ~ ¢ �� � � � � � � �� ��� � �y � � �° � � �•� � 1 \ "'.' P '°�''.� ,+ �' O O v, g �n.P. v-� SL rt.c � �'' h . �' \S- '.i '� r m O � \ � � � �Q�,ro �o,�, Q � �� � � ��,� �a ,�� �, � t t 4 � � � a� ��r�:•��,n�n,��c''� ;s��c�000 o�w ''" �1t � � ` �r, d Q O�v0 ~ -�t� i'e-�'A O C3.'O nF � �� � g2 qy� ,�'p" �V �� � 'V� � t � `k �+'" P� F' C O �TV`x P.,�N '��.. o v� ��.n S ('�.p'C.� ti.�� � Oo . ' �^� , ; � � �� � O � s Q'A y � µ¢�.�3 y C y n Z"N,T,'R y � " 4 � � N C� �w i0 �, a �, ��� �y°' o�i�, <'H'yoQ `° ' �o o��0 � `` ' 'r. r�o �s co on��vQ-�.,�..'a � �c`'o :o� :"Q � ov.~ � o�°`� � � �3 oa a� wdc� oca„., o ,'�,' �.° � �' � ,-r. 7� � �i` O �r �' S 7 0� t�'p.,c�o R''-. ��a�o Y m m � Y m0 O � r. ,G�, ¢,s w.-�.��� .�o 00 �' p�°�� ' '�'a e�''~�`�,�',7 '� � P� o. �«. m �'a � `" � �,,� .._.o `"� by�' ,t '" ��r O „� ��+t � ^s� ¢.SZ.� O y f.�"`.G. � ¢ ,��y eo 'o p .�N •�'i: .+'� A �� ,Z �y� � �� oo Q��y�� �� �Q�Q. �� ���� 'Z .cy o� Y, s.�: � ��: ' �,, � c. '�." co ,.. o_ - .�� c''$.r.�£ ��� o� n� o 0 " 3" � C-'" ° " Rb �c � ��4»�'�. ° a�''� °� N "" o�" � �„�; � ~G a, 'O ' � .c ' ✓' � m •'S'� p,.'9 � f. O � � �'-"� �p`�'co :°4 ,1,,,.✓� q o O'R p X � io m "' ' �O �io�C S.�C Ca � �3'���'C.�� ../„"`„'�' � A �, �io O �C'� � �,�y�j;,,Y ..^,...e"� O °y". . O�p' �p C� � ��,�,,.-"'`_. . , � O x��.--. /^�,.. J R �,���- ��.i f�. ..��,i F�