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�