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HomeMy WebLinkAbout1761A WORKERS'COMPENSATION DECLARA7ION ��� . msJ reby offirm�that I have-a�cerhfimfe pf consenl to self�..... .. .:.. . .. � ..._ . . . .. :. .. ...�. . .. .� '��. .. ��.. . . . .. +i I hefe;ar o certificate of Workers'Gompensation Insurqnce,or ' �� �aAaa§o �� � . . � "�" � " � � ���� °u ����.�a cert fied_copy ihereof(Sec.3800,Lab C.) - ce eoe�Rev.eiei I � /��p! f/�w T0O N eOp �r - � '-PolicyNo. � Company��:. . �. � - �s . . . . .. . PM1 rL 4rP1 �' R �CRM��.. . . . . . .:. ... _ : , , _ .. . SEWER • SEWAGE DISPOSAL � ❑CerLfied copy is hereby furnished. � � , . _ . S' �Cert�fed„copy is filed with ihe counry building inspection COUNTY OF LOS ANGELE3 BUILbING AND SAFETY .., ., depariment. . . . . . .. . .. .. . . . .. :... ... ,. . .� . ,�. . � .. . . fSa�e ' ` ApPlicant ` `" FOR APPLICANT TQ PILL IN ,��G��. CONNECTION DATA` CERTIFICATE OF EXEMPTION FROh1 WbkKERS'������� ��� eunoiN� . . � - ' COMPENSATION�INSURANCE� � ���� ADDRE55 .(} _ L.,Q.� � STATIoni a-�..�i'�r� DEPiH ..- �� (Term te s,Ifor one hu�dbed dolPoe�ted�rf the work involved by the � � �-�� i�A�nY � � uwNHo�e ReFeaence � J/"` /� � ��ER ,- (J (SI OO)01 IE55.� NEARESi � � TYPE OF CONNECTION � LENGTH FROM `�I certify�thot in the��performonce af the work Ioi�which ihis � .� ce0.555*. ~ � v. � cuea P.t. ^.+.i.ro v.�. � - � perm t is issued, I shall not employ any person m any manner . � . � �` sa as ro��k�ecome sublect lo the Workers'Compensat on lows. v.c r�o.- - / y� : ,. , . OWNER .,. i a �" A r CO.IMP.NO. ' ' JOB N0. �j'�� - '.: : '.�:: :: .. .��. , �"�.�„ . hU1ll Q /'� . ... . .. . !y> '�Dtlfe APpICO�f � ADDRE55 I ! O'PE�{ti Y ` x,Zl TRUNKPERMRNO. ROADPERMITNO. �+ '��tJOTICE �TO APPUCAN7 If, after�making�th s Ce�iificote Of CiTY AFFIOAVIT �VAIVER EASEMENT RECORD,INSTR:NO, DATE � " Exemption, �you should become subject to the Workers' ✓'� TE�.No. 7 � �a 7 a ::-�Compensation provisions of ihe Labor code,you must fonhwith oescaivAr�ioN �OrNO. � � �� Nwv.oa sr.wioen�iN� � ������omply with s�ch provisions or fhis permit shall be deemed a( - �+ - ��I2vOk2t1. BIOCN iRACT - [ � STATE ENCROACHMFNT � � ' � � '� � - � - '- -"LfCENSED CONTRACTORS DECLARATION' "'"' ���� n'o.oF a�ocs. v�aMa No. � � � 'T `�� I hereby dff rm�tho(�I�am licensed under provisions of Chapter ��� SiaEOF�o� Q � nowon�or � ."9�commencin with�5ection7000 of Division 3 of ihe�Busi- ' USEOF� / ( 9 � BUILDIN65 ^h L� �P' 'C yG C}IARGES � : -ne55 and„Professions Code,and my license is..in#ulf force and . , � '�';effeC�. �ONTRACTOR � xt � COhNECTION CHARGE FEE . ,�. .:.., .i.'... .., y .... .... .... ���L CeI15E NUfYtUE� � LiC CIp33 ADORE55 � REIM6URSEMEM FEE � '� COniraCtO�� �Dote . . � CITY ,rEL.N . f�I �.� � �ISTRIC7 NO. G�JUP ' MAP'..... . PROCE55ED BY� .:. : �� .:: :... .,, ,.., " -y I . BK FG �F ' ❑I om exempt under Sec of the L.A.Co. iiTeerisE uo, - /� aass t v� i �.'�j' �f--�1 C �'. (�,r(� ��"i � . :�:..�- . . . , . . .... . '.. '_.. .':� NC. D RIPiIONOFWORK ... ..ffE .... P . Plumbing Code and/or Sec. - - �of the� �� - Fwnt � , �,:�. .....�': "'� '-- ' , �,:-': 40USE SEWER CONNECTING T0 � ,✓f ��f �AiE r� �� VALI ATION � ��- ' ��� ' PUBUCSEWER B.&P:Code for rhe follow�ng reason sevric TnaK,seeva�e aiT oR� � --���� ���� - ��� � ���� � � '` � PiTSAND/OR�RAINFIELD�� " ' FINAI ' . - .:., ...;;. ..��� .:.. .. � ..... ... �ate...... ..:.:... ...: 40USE SEWER CONNECTING TO.. ... . ' 6v � ,. ` - � '� '. ,:. ,.'�� ?RIVATE�ISPOSAI SYST M1 . � $gnOlUre ' . CONtiECt nUDIT!ONAL BLDG.O,R �'" '� ' �' � - OWPfER Bt11LDER DECLAR,4TION ' �"� " ' �nroeK ro Nous�sewEa � �- �� ► � .�I hereby dffirm rhat f�am exempt�from t6�e Contractor's License �� e°iiErvF��essaooi oRvweCAHnNvoie � ��- � . ��� Low for the foll6wing reason(Secton 7031:5,Buisness 6nd Pro- nlrEa,aEva�R oR ABANDON HaJSE " � .���fessions Code):. .' . . . .. sEwea oa oisaosni srsrenn '_' . .........._ ^," j jz 1 A ..... . ...... _. . .... . .. . ._.�, . ...�.._ _ ....._. . - . : ❑I,as owner of the property,or my employees with woges as , n their sole compensation,wiil do fhe work and the structure �y; ° ' ' � is�no�intenrled or offered for sale(Section�7044,Business � and Profess ons Code). � � � aWNER'S Permit 5 � '7�` ,�-j,��� �' ❑I,as owner of the property,om exdusively tontracting with AUTHORIZAT�ON TOTAL FEE�� - ' L�` licensed wn�r4C}ors}o ConsifUCf Yhe PfOjeCf($@Ction 7044, I NAVE AT THiS DATE.A CONTRACT P✓ITH TFE HEREIN NAMED C6NTRAC'OR O . � �- �'���' -� Bus ness a d Profess ons Code) CONNEC'THE ABOVE�ESCRI6E�EXIS'ING�WE'�_LING'TO TME Pt1BLIC SEWER. � . �'�: CONSTKI'1CTICSN LENYSING AGENCY ' ""'� '��"�- - ,�+,,.t� � �^ � � �2 ��,C C-':%% r - I�herehy�affirm that�ihere is a cons�uction��len)mg agency - � SIGNE�7HI5 � D dF.�.S��i9�.� ► - �� for the performance of the work Por which ihis perm�� s � a'"f"'`-Ro°� { � � issued(Sec 3097,C�v.C.). � - , owNe�sn�ENT � �2,cf .. . ., : .. ;, .... .�.:. . ��:...�. . : ADDRE55 C d L Q ' Lender'sName� � � ' � �� '� . .... _.. . .., .... . ,.. -' �.�:. ,i..� ; ,.., - �:.r �; �;"' -'..:. ':t., .. _ . - � �cLender'sAddress .. . . :, ��, . ,: . . ,`^ '�,�..' '�� '� ��� .. ... . _... . _.. ..... ....... . ,. ,.. _ . . ... .._ __... . .. .._ _ __._ _ _ _..... . _ ... _ .. ...._ ....... � . . . _. . . . . .. . .. . . . . . . .. __ . :�1 cerhfy�that�l��have reod�this�applimtion and state ihpt�rhe . ��-�above information,is correci.I agree to comply with all County . � � � � . . ordinances ond State laws regulating Plumbing and Sewers, - � ❑nd�hereby authorize representotives of this Coun�y to enter_ � . . . � � . � �u e a6ove-meMioned property for inspeciion purposes. �--���,r-.-.- 9 -G �-83 Signature af Permiffee Dafe SEE'REVER5E FOR�EXPLANATORY LANGUACE - � " ' " -- � '� � �-� ' ' ' _ _ .. .-- _ _ .. _. .�.:> r�;yw�cTa�s����wrr���s :��7Pd�It��;L�?��:Ei,Y AR,t�'�'TO?a' „ z,;, , .�___ . k ! . - . �__ .. . . . . . . .��e �.....�_ . .. ... ... ... ..... .. .... .. , �����q,,��°��, �AT'_ � �INSPE^•TOR'S S�GtiATUR' � _______.___ �1',Pl':F':-Efiai'lu ii13f dRt�;:i.Af1Ct iI0.2 2.i�:s1nLf3GQQC'S . . — .� , . ... .. ...:. � . - cc�se t.aa -er t�n:e o�iows�n:�.easnr..(5er.�'asc 77.�1.5, Ne,vHous[srwrx � . � : � . . . � ..�.seaae;s�arc.4. F�:f�sair,:;� Ccve� n.:e,y city c�-._:rouaty . . . ._,_.. .. .. , . _,.. ... _.�.—� _:_---_--_ —...—.___.—...__ � . _. CONNFC:R'JJITIo4�L � � vt;idir P2:f.C�r+.;�C h2rro;[,`,ec COY.sC�c',.�Zeer� sNebr�x.r„ BU0.DING OA WORK _. .,.�- .. . . ...... ... . ;...� . � :. � � . . : - SEPTIC TANK.SEE4.FIT151 � -� :.: '— . .., . — —�---� _'—_—'__—"__—"_'_ C�^:Y<Oi°F..,�T 4G1'i!{..^451'y 3'.Yd.•cLfLt_,��za.'w��Sti S�Sss6fRCe� AND/OR DRAINFIEL'J ' - � afs-i YEG!b5:C: PJJL [>$�94ELkttL J��..'S:t:,h 1'Ii+YYl2lE !c f4.le a — � >4gsa�s sd:zt � n>,t :.4¢ z�adca d�u�;s�e:ar.t to tha " CE55?00:❑ ORYWE'.L❑ ' —` . —__-�_ . , . . — . . .. . . , ... . . � � . ,�o�e.?aws ef r�.Cc a r [.xras L..:v fGGapse,^> . .. . .. .�� . �.. . .. . l�LTER:AEPAIR.'SEWER O'�� ' � ' � � � Sewn�e o��svos.��svsTew. �. i.. � .- � � . _. '.._. -��—'-- .. . .. (or ner.ceaq �:tii S c�so.� 7CvC)or�kvii:.�n-3 of coe . _— �. . . . �fb.�>!E S. 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