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HomeMy WebLinkAbout1768A I � - WORKERS'COMPENSATION DECLARATION � � � . , �j'�, ��hereby affirm thot I have a�ceHiflwte of.,conseM to self � - � . ,�- ��.� �..•. '�w. . - insu�e or a certificate of Workers'Compensption Insurance,or � �aneaso � � . �� - „,� �. � ;;, __�.„ „.,w.�� �,^<•""' � �r. a Eeriif'ed copy thereof(Sec.380Q Lab C.) � c[ece��eec•.�eiei�� � ��ppLICATrbN �FC�R �'E��hAIT .. .. ...policy No. ..... . Company .,, ....., .�.,..:., @s .,.:.. . .. ,... � .. � ❑Ce fified copy�5�.ha�ebY f����shed. � � � � � SEWER � S�WAGE DISPb�SAI ; ,.. :.�. _ ertified copy�s 4iled with the county building inspection '" COUf��F�OS ANGELES BUILDING AND SAFE'TY . - , . ....... _ ... �department., . . .. . . . . ..- . � ,. �,.:. ,,,,..i,,,»�:.. . � � ... ,. _. .... . . . . ._. . -..._.._ . ...___ •. .._... ... Dafe . .A licqnr ... . ... -... ..- T TO FILL IN ... . f ,,� f�. ap ,. �..,.. FOR APPLI- ...� 9 I� CONNECTION DATA �' CERTIFICATE OF EXEMPTION FROM WORKERS' � � ������� � '� � �;COMPENSATION�INSURANCE � �� Aooaess�_ �. Q � � � STpTlpN a�„� 'oevTN V _ . ...._..._.� ... , (This�secrion need nor be complered if the work involved by the ' MnNnoie acserzeNce� � /� �wwea iocnurv y4 Y' ...._.__ . �'G � :• . permit's for one hundred dollors(§IOD�O�IESS�) � - iYPEOFCONNEQION � ' ��� � � • '. .• .. :. ... NEAREST'�� .... :FNGiH FROtii . � I certify ihat in �he performance of the work forwhich this ceos557�." � � � � �-�•-••- � CURB_,,,_. P��� M.LTOPL..y,,,,, , ..,,,� :v' � permrt is ss�ed,I shall not employ any person in any manner - ��- � /r � v c No. i � so os to become.su6ject fo the Workers'Compensa}ion Laws. owNea O. " �} -�\. co.�Ma.yo . ioe No,,,, � �. �.. � �..�:s' ���.. .- .... M411�.. . „ �r f �7C TRUhKPERMITNO ' �. • ROAOPERMITN _,.... +„s Da�e._,T___A�JPIiCO�t . �...: ..�v �...�..,.r.+:. ADDRE55 Y'�� Y AFFI�AVIT WANER EASEMENT RECORD INSTR.NO �DAiE *1 �.�NOTI'CE TO APPLICANT:�I€, 'aftar making fhis Cert ficate of aTr �p :rvo l� br �7 � .�� Eaemp�ion; you shouid become subjecr ro ihe Workers' - � � � �-. �.....,_. .. �� revokedwith sch ovisions o� th�s.._. :.. Y gtcE�A� . �. . .. .. . ... � Com ensa�ion ro sions of fhe Labor code, ou must forthwith caivrioN �oTn�a .... . Nwv.oa st wioewNc� . . ,_ _,. y, ' � p y pr permit sholl be deemed �' ��'"=�-� """' - " - � � � SiATE ENCROACHMENT- �'. . . =�> ., ` , �:^ -..�.`..'..� C% . _...� � � NO,OF B W5. - GERMRNO. . ... . . ��. - _,. . ..,.. .,., �, . .�. ., � ��" �`LICENSEDCONYRACTORS-DECIARATION� � srzeor[oT Q NowoN�oT �. � � . . .. � . ....�..� . . ._._.« I hereby affirm ihat I am Iitensed under provisions.of Chapter � . . .._ .. USE OF CHARGES 9(commencing with Section 7000)01 Division 3 of the Buai- aur.o'iNGs yl • �r' � ��--�'�-��F•- ^ , ne55�and Piofessions Code,ond my license s n fuli force and mNrvecrion�CHnRGe�e � effec� . . . �,:;. , .,-,-:�.., ,.. :. ,,,.., .: �..... ...:. ... coNraaaoa j L � ... ..... . ......._.. �... � . _. .. License Number L c.Closs ....... ,�.•.--• � �� �/_ � RE�inne0R5EnaeN'r FEE� � �� - � � ,. ... ;., ..:...:_ . ADDRESS� .... . ..� _ GoflfrOCiOr � ... DOIB .. �. � � ' • � r DISiRiCr NO. �UP �MAP P�R1OCESSED BY ........._..:..-:_.. CIT" ; TEL.N �I . � 7 / V SiATE . uC- !� gN //�PG �� ❑I am exempt u de�Sec � . - of,the L A Co. , uCENs�NU, �j- nnss C��� '� '(�� ���.A�� ��� � Plvmb�ngCodeand/or5ec - . ..•. ofthe� No. � DeSCR�PTIONOFRK � �F � FiNa � . ...'.�. ,�:' '.:.� � - . �. .... -�-' HOUSESEWERCONNECTi.O '. . .... /✓��.^p�� PAiEL � ... VALI ATION _.._..,__...... . Pt)BLiC SEWEP '. ..... . .... . ..:. / � •. 9�� � � ,.,,.8.8 P.Code for rhe following fCq50n : ��� """ SEVTiC TAnK.SEEPAGE CI� FINAL � "' " PITS AN�:CR DRFINFIE:C BY � mru�v+.�.h+'*+�DOIC � HOUSE SE`NER CONNECTifO � . . � . ....-....., ..». . .:.... .,,.,.... '...::.` ..��.. . '. . .'.�� .. . ..� � . PRIVATE�IS?OSALSYSTE� - $IJndfufC . ----� �^•�'� ">-=::'_� -'•'�'`�'��:• . �.. CONNECIADDITIONAtBIOR , '�" :.�OWNER-BUILDER DECIARATION -� � woak�roHousese�ea. � � '- � OVERF�OW SEEPAGE P!T,!NfiElO .. I hereby affirm thof I am exempl from ihe Coniractor s License E:tiN.,CES5aooi DRYWMA�:HOLE � "� Law 4or the following reason(Secton�O37.S,BUiSnESS On(i Pro- +1L'ER.4EPAIR04 AdAN HOUSE . � �f255iOf15 CodC): . . � SEWER OR D;SGDSAi SVS! . ����o .n .....,. ;:� J � �i I,os owner of fhe property,or my employees with wpges as -...• - � -->��+�� .. . ��iheir sole compensation,will do the work and the strucfore . . +=" p1 " a � J � �. .. - .......,. ._._........ ...... <. .-�is noi inrendad ar offered for sale(Sedion 7044,�Business �� �. �.dnd��Piofessions Code). - � OWNER'S ermit E /,'_h�� -1 � F���C ❑I,a;owner of�he property,am exdusively contracting with AUTHORIZATION 'OTAL FEE ,.. �.� 1�� 'Iltef152C�COl11YaC10f5 10 COl15�fUC��Il@ pfO�ECf($¢Cfioll 7044. I HAVE AT THIS��ATE A CONTT W�TH TNE HEREIN NMAEC CCJNTRAC.TCR'r0 � �. ��%�� ���BUSInE55 O�CI PfOf¢SSi0Y15 COdCj. CONNELi THE ABOVE DESCRI6E�iSiING�WEtIING TOTHEFII�CIC 5�'f4ER.- . . . .. ....��... .. . :... ��� �CONSTRUCTION LENDWG AGEN�Y��� ��� - ,.L��� ( ► � �u-��2 I hereby affirm thot there is a constronOn lending agency SIGNEDTHIS � "'-B Of�__ ..—_��.,1_��9� for the performan<e af rhe work for wh�ch ihis permit is °�"'N`Ro°� / . issued(5ec.3097,Civ.C�. , owNeasaGE/N�T /� ��� . �^��-'�-�-�,��'�'��y�'�• . . . .�.. .. .. . . .. . . A�DRE55 /6�d �✓w; :L�'^ . Lender's Name -.. . ,.-....,wn.,,,.in�w.7 �:. c-<nier . . . . . ... .. . _.... . ., �.;. -.�.... . . � ..AiS ...�..�.:,�. .Y.. . _... . ... _..... . . . � �-..�..�.M-r+- ...i .�. � xv.rn....�—r) •'•.. ., . a' w.:� .`.,..-.:�: ....__ , � Lender s Address . - ,•>.,,- <,'��+?-'�'��' . ,,.. :..��� . . . .,.... ,_ c.:m,:.:_,...s .....� I cenify�thar I hove read rh�s applka�ion�and state that the � . � - . d6ove informolion is mrreci.I agree+to comply wifh all Coun�y - � ordinances and Siate lows regulming Piumbing and Sewers, � � . ..... . . - .� - - � - and�hereby aulhorize representafives of this Cpunty to enter ._ .. ... -� ���� � � � � ' � � � - �� �� . . .,. .. . - - - � � u.`."..�ie above-m ntioned roper�y for inspection purposes: . . . ..... .. . � _ .. . ... .._ . ..... .. .. ... - . .c... .. . � - . / (�/ � _. . � � �, , . , . .. ignature of Permi�ee .�afe � , . ��SEE REVERS�k EXPLANATORY LANGUAGE � �� , � � - � - . . .- .. .: .. _... , ; ..., ... ' ,�.. 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