HomeMy WebLinkAbout1768A (10) I - WORKERS'COMPENSATION DECLARATION . ,_� � hereby affirm thot I have a�certif�cote of.,conseM io self � - .... - insuve o a certificate of Warkers'Compensption Insurance,or � �eneaso � ; �� �- �� __„„��..,w.�� � •�_ -� � � .,. .�..,,�«. . .. � ._ ,t� .� � � a Eeriif ed copy thereof(Sec.3800,Lab C.) � � cE ece��aev.�e-ei�� �pp��CATrbN FC�R ���1111T .. .. ...pqlicy No. .... . Company ..,.,...._, �.,..;., @s ep ...:.. . .. , ; � .. � ❑.Cerfified copy is.hereby fumished. � � � SEWGI� - S�INAGE DISPb�SAI ; ,._ ,..,. . _ �._ ,. ertilied copy�s 4iled with fhe county building inspection � COUt�OF LOS ANGELE'S BUILDING AND SAFE'TY " ,ideparrment. . ., .. ,:��....: . .��... . ��� _,..�...... >„,a ..�- .�,_.,.w,,,,.� ..... . .. ..:� ......_ . .__ ...- ._.. ... ,._. _......_. . Dare Applicanr ... ,:.. .•.-- FOR APPLI :T TO FILL IN.... . . ., f 9,,��� CONNECTION DATA � CERTIFICATE OF EXEMPTION FROM WORKERS' � � � ��� � /7 '� . BUIL�ING L, ....� 5`ATtON q��n� �PTN ,.. '� �;COMPENSATION INSURANCE �� n�oaess�_ �. '- /� -��--��-�- , (Thi's�secr on need nor be complered if the work mvolved by the �� MnNnoie ac�erzeNce � � �wwea iocnurv y4 s�" _._.._ . �'G :• . permit is for one hundred dollors(�IOD�O�IESS�) � - il'PEpFCONNEQION � ' ��� � •..... . .. .:. ... NEAREST'�' ... :FNGTH FROM , � I certify ihat in �he performance of the work forwhich this ceos557." � � � ����-�•_- � cuk6,,,_. P��.� M.�.tori..._,,,,, , ..,, q" � perri�rt s ssued,I shall not employ any person in any manner - ��- � � v c No i � so os to become.su6�ect to the Workers'Com ensa}ion Laws. ^ �� ce.iMa.no ioe No„, � � ..,. .., 1 . P owNEa O -^\. ....,. ..,.._.�, , � ., �,nnil ,. Ir f •�Zt TRUhK PERMIi NO � ROAO PERMIT N �! Date AppLmnr .,.,,x.+,. nooaE55 �y.I' Y � / --.'...� . ....,,�,.... ....._. . .,..�.. � � ��� ���ry �� AFFI�AVIT WANER EASEMENT RECORD INSTR.NO DAiE *1 �NOTI'CE�TO APPGCANL�I€, 'afrar making fhis Cerf ficate of ���7v � ;rvo l� br Y� � Exemp��on you shouid become subject to ihe Workers' - � � � �-�. �.....,_. . 3:� ., LEGA: �. . .. .. .. . .. � Cor.�pensai�on prbvisions af fhe Labor code,you musr forthwith . oe5caivrioN � � .�oTn�a .... . � - � Nwv.oa 5*.wioewric ,, _.._, y.: '�comply with such provisions or fhis permit sholl be deemed �� ' ""�-'�-�""""' - " �f@vok2(J. . � - � � SiATE ENCROACHMENT� . �'. . . :.. ,.:.., < ....� .::.�.'. . ..... . . a: ... ._, . ...... ,., �� . .�.... �"� �`LICENSED CONYRACTOR9 DECIARATION� � :"� g`ccN + �� �+o oF e o�s. PeaM�rNo � � � . '. ,. . SIZEOFLOT a NOWONLOT � ' .. . -.-._.� I hereby affirm ihat I am Iitensed under provisions.of Chapter � � . . .._ .. . ...._... USE OF CHARGES ..,, .9(commencing with Secfion 7000)01 Division 3 of the Busi- am:o;NGs yl v �r' � � � ���'�-��v nes5�and Piofessions Code,ond my license s n fuli force and mNrvecrion�CHnRGe cEe ef4ecl . . .:��,:: , . .-,-:�.., ,. .. ,,,.., .: �..... ..... ... coNraacroa j L � ... ..... . ......._.. .. . . _ . ..... ., ... : . � C . ... ._. . License Number . . Lic.Class ....... �...---. AppaE;s� p �/- ae��MaoaSenaeN�FEE� �� - � -. .. . . ... . . . . ...... ....._. ... . . . . GoflfrOCiOr DOIe ... : � � � . � • � DISiRICr NO GR UP MAP � PROCESSED BY ❑I am exem 1 u de�Sec �� of the L A C � � � aT� � ie�,m f/ � ' � �/ y / SiATE . ' uC- ✓', �. BN (�/�PGb/�' /✓��i P . .. , .�� , LICENSf.NU, �- CLFSS C � ��+f`p/' � _ / 3 � Plu b�ngCode and/or Sec ..�,•. of the� No � [,eSCe�aTioN OFkK � � FiN;, • . . :. . ... � ::.- � � ..�','. ..': - :.� -�. '. .... � FOUSESEWERCONNECTi.O � !d 'p �AiE ��� / VA�� ATION _...... .. .... . ' ' Pt1BL�C5EWEP '. ,,... .... : / l ^�� .... . „.,,.8.8 P.Code for rhe following fCQ50f1 � � �-� �" '�" SEVTiC TANK.SEEPAGE PI� . FINAL , •.. • P'�TS AN�;i.A DRFIMFIE'.L BY � ���--�+.'�'++'*+�'�DOIC . HOUSE SE'NER CONNECTIfC .....,...�,...o.. . .:.... .,,.,.... . ' , ' ,.. ` . �� . PRIVATE�IS?OSAI SYSTE! - . .... $IJnOfufC �... � .--- ,^.�-� -=:'�:- �:z%`+�:' ^•.�.. CONNECI4DDITIONAIBIOR .. , �"- .�OWNER-BUILDER DECIARATION -� � woaKroHous ,ewee. � � ' OVERROW SEEPAGE P!T,!NFiElO .. I hereby affirm thoY I am exempf from ihe Coniracto s L�cense ui� CE55aoo�DRYWMA�:HOLE � Law 4vr the following reason(Secton�O37.S,BUiSnESS Ono�Pro- AL'ER.4EPAIRCR A3AY HOUSE . �f255iOn5 CodC): . . � SEWER OR D;SGOSAi SVS! . ����o .rn` .....,. =�� 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 � � �� - .......,. ._._......... ........ <. .-�is�noi inrendad ar offered for sale(Section 7044,Business �� �. �.dnd'Piofessions Code). - � OWNER'S ermd E 4';h�� "j e s(7,�Q ❑I,a;owner of�he property,am exdusively contracting with AUTHORIZATION 'pTAL FEf ,., �.� 1�� . -:�licensed contraciors+o mnstruct the project(Section 7044, i HAv�aT THis oare n coNrr wiTn*Ne Hesew Nasn'-e cnHrencteR�ro . °C.�f�%��_ ��BUSInE55 O�CI PfOf¢SSi0Y15 GOdCj. CONNELi THE ABOVE DESCRI6E�iSiING�WEtIING TOTHfFI1�CIC Sk'WER.� . . . ....��... .. . :... ��� �CONSTRUCTION LENDWG AGEN�Y��� ��� - ..L�- ► �,.�u-v 2 I hereby affirm thot there is a cvnstruclon lending agency SIGNEDTHIS � "-B Of�__ ..—_����9� for the performan<e af �he work for which Ihis permit is °u'N`Ro°� / . issued(Sec.3097,Civ.C�. , owNeas aGENT �+�� ��-��-�����'• � .. .. ... . . ... . ... ... .. . .... aooeess - 7��Pd Lender's Name -.. ..�.:_wn.,,,.wt+�w.f �:. c-<niz . . . . . . .. .. . _..... . ., .;. -.�.... . . ��ss�r 4W.P -.A�5 ...�...�' . . ,. _... . .. _..... . . . � v�r...,.� �-.�.:�a.M r+- .::.5:� .�. _..-' ., . ,nY..�.' a w.:� .`.,..-.:': ....__.. Lender's Address— � `^'"� "•'���•-� ' � '"' �� � � I cenify�that I have reod ihis applica�ion and4state that ihe� � . � - . d6ove informolion is mrrecf.I agree-to comply wifh all Coun�y - � ordinances and Siate lows regulming Plumbing and Sewers, � . ..... . . � .� - -� - and�hereby aulhorize representafives of this Cpunty to enter . . . -� ���� � � � � ' � � � - �� � . .. . � - - � � _ . .. , .. . . .. u."." e above-m nfioned ropeny for inspection purposes: . . . .... .. � � _ .. . ... .._ ....- .. .. ..� .. � . . .:... . � - . � / � � _. . p.,_ � .-- . .. ., ,.. . ,. , _ . � � ; .. . , .�:....: . . ignafure of Permi�ee .�afe , . ��SEE REVERS�k EXPLANA70RY LANGUAGE � � - ���� , � � �- - : . .. .� '. ,: . . � �. . . .. . . � -�,' _�� . , ,. . -,�� . _ , �.- . �� . .. �- . .'_ .. . �. . :... _ ,,.s...,,.3..�-. . . . . . . ..:. . :.:,-.. . ._- .., �.... . . . . �. ._ .,. . . . ... . .,,� .. . .�"�^---.... . ..v.....,..�.�...:--.,...,.� _--------,. . ,- .,. , _ .�,�:a...,: . . . { • � ' ;, :, ;;. svEctchs�oF�s�.._ � a,� C�. =3,Y EK LL?TT L:,Sd T,Sr. �A�tATICiN,, . . :..e': � < :•: `<�.. ._.. , ,.. <---- . - �� � � _.. . • � ..a e �6j af ir ...,c . -. '� r &c�-n he roPt.ra toi's � � " �pTc INSP CiOR'S SG\ATJRE " • . �(31��acOVA�� . ----- Licer�� l.ay.sc,-.he:ct':oy n s-seor lS.t.los 7031.5. --- ------' y .., o cosshS NEwHo�s Fr� � _ ��:. . : . �� . .. .Fis< -�.s� nd P,f ic s de?rac r>It . prnve, r� y * — _ . k trs� _ r— �iuG cn r2r. ve3 P�"� � � ,smance, .. COhN Cf P➢D.'O'vAL —�� . -�. . ..� ..�. �.. . :�... �. . BUIl01NG OR WO4X . . . .{c;sAolt rJ . YL c�T � n s����r�£���c j'466-4 __ �� . .. ... .._. � . .. . ��6/sG ¢§.e, � afSp7.., fr Q 5EPTIC TANK,SEE�.P (aj ' . � . . . � AND/OR DRAINF![l� . . .. . . � ... ' _ . �a er7 et¢z:, x th'¢ Fo a cer a rsrzc:t fa Ebe — � .r""' ' �._ CESSPOOL❑ okVV�EII G� . .� . . . ; . :...... . ,_ � '.. �. .. � .. - � afL c � �w as � �Ph r'�nerrc.c .z.sr �c.,�(�r.�spSeP . . _ � . 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