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HomeMy WebLinkAbout1762A , , �F r, � .� w.� _.. .,, � .,�� ,. ...,.. ...._. _ <� .,. ,... ,.., . .,a,, .. ..,.: .,... _ .,.. � . ,.,. ., .. I WORKERS'COMPENSATION DECLARATION � � � � .. ,., , . .. . _ � . .. i� I hereby affrm ihot I hdve a�certificate�of congent�to self � � � - �� � . � - � � � �� �- �-�� �y � nsure,or a certifimre of Workers Compensation Insurance,or j - ianeaso - �. . . � � . - � . . , , , , _ . ' Po��� No. �om a�80°,La6C} �E�e�RE�a,a,. �►PpLI�pTION FOR PERMIT a Cerfified co ihereof Sec.3Y �5 PY ( Y P " ° SEWER - SEWAGE DISPOSA.L , �.,... . . ..... 7.Y,. 9.,�...:_. .�.�..r�: .�.:,� _. _ .. .. �` ❑Cerrified.copy is�hereby furmshed. � � ' -- ertifiedmpyrsfiledwith�.rhe�coum 6uild�n inspection� : � COUNTY.QF�LO$ANG.ELES. ., _, �_ BUILDING.ANDSAFETY , . . :�.:department. � . . .. ,.... .;.. ._,_.,... . � ._. .._._ _...._....._ . :_. . .,__� "Dore :`qPPlicanf '� ' FOR APPLICANT TO FILL IN .. ' 3;���� CONNECTION DATA ..�. ".�CERTIFICATE OF EXEN(P710N FRONi'WORKERS`N.�: ��""..: •.-......- . . � .... . ._ „_...., .„._,.�..._._,.. . . . . . . . ._ . .:�: .. .. / � ,: B�iLDING A '�i � StATIDN .���!K-� ...DEPTH .,;;, COMPENSATION INSUkANCE ' '�� � -- nooaess � v L � i - � � (This sechon need no�be complefecl if fhE�WOfk inVO�Ved by ihe � �pCALITY � � � pr Nl4NHOLE REFERENCE �� � E R permd is for one hundred dollars($100)or lass) - � � ... . . . �-� ---- - �•-•� --����-�-�---- � . . :.. -.:'.:. . .. NEAItEST � . TYPE OF CONNKTION� IENGtH FROM +` � I cerify ihat n ihe�performa�nce of the wo k for-which ihis ck0.555*. �O v. cuae P.L. H�T�P��� perm'1 is ssued,I shpll not employ any person n any manner ' � -�-�� - � � �� � � � P.[.No. � �. �" ,�/3 ' y � so as to 6ecome sub�ec�to the Worke s'Compensati6n Laws. � -. r�� ♦ yi CO.IMP.NO. JOB NO. �✓:� :. , .. . . . OWNER �� , . . :: �� � "� �"� :. � . ��� �1: . TRVNK GERMIT NO ....�.. ..........ROAp PERMITNO. � Date � Applicant � �- ' � acokess Y � � - - � .. �.� . , , , ' AFFIDAVIi WAIVER EASEMENT RECORD INSTR.NO- DATE :P- � NOTICE-TO APPIfC�iNT �If, after makmg�this �ertificate of � '� ��t�. � re..n�, ` /Z — �� •„r �Exemption, you �should become subjea to ihe Workeis' � ,E�Ai � -- � - �� .. ...,,._ i= ..._.. ......,.......__»,_�.-...�... � "Compensation prov�isions of�fhe Labor code,you must forihwifh DESCRIPiIpN iorNo. , r�wr.oz sr.w,oENiNG � y; comply with SUCFI �JlOVISIOf15 or 7his permit shall be�deemed - � ����"��"" �"" �� ����- �� ����- .. . ._..__:....._ ....„.........r, 2: _..,......... - �� revbked. a:ocK TItAC7 � � STATE ENCRDACNMENT ,,. � ,. ,�`..LICENSEDCONTRAC70RS DECLARATI(7N '��.. {. .. �. . .....�.. . . ... . .. ... .. .....'.... .. .. .. .. , �� �q /� N6.�OF BLDGS. � PERMIT NO. .. � , ...: ..., . � , �:� S:ZE OF LOT (/O V NOW ON LOT ... . . . ... . i hereby affirm ihat I am licensed under p�rovisions of�Chapter � � u5eo1 -� ' / �-� � � . 9��(commenang with Section 7000)of Division�3 of ihe Busi- � em�ow�s � d.� 6 v L'S r [Jo � � cHnqGES """""` "�"'"""" � . .... _.....:.. ...,... � ness�tind Prof9ssions Code,and my license is in�full,force and� � � - ��� -�--� � � - " � � �-� _ . . " effe[t. - ' ' CONTRACTOR a CONYECTION CHARGE FEE . • .... ..... . ... ........... ......, ..,.., ......,.._.,_,......w. L�[En52 NUmb2f � �L C.��q35 ��� REIMBURSEMENT FEE . _ ... .i .. , . ,.. . ADORE55 � Contracror ��� ' 'Date ��� � �t�� . j�ll r � �ISTRICTNO. G^ROU� MAP �-� - PROCESSED�BV . '. .' � ' . .. ..' CItY ✓�!� �P gn' 7 � u� BK �G �. . ❑lomexem tunde Sec. �� ofthe�L.A Co. �� sTare � " ���`� '�� uc J,x i � r � . ��j/ . P LICENSE NO. '" S C1A55 .�- � � ���y�� L/."✓<,/ �,. Plumb'ng Code and/or Sec � � �� �of the � � NN o .... f.•..�,... ..�.. rE . . ...._.._ r�o. DESCR4PTION CF N10RK `�K�� F•N - . � . „ :,: Hoase sevea co eaini�r {��✓� onA` i� VALIDATION B.&P Code for jhe following reason �' � � ' �-' ` Pusuc sewea � � � ,...; . � -..-. SEVT;C TANK,SEEPAGE PIT.OR ,."","•'••'".•` .'.. ' ��':� ::�. �� . ''� . . .�' . �. . '.., PI�SAN��OR�RAINf1EL� � FINAL .. .. ��'�� • " �Ot¢.. . . HOUSE�SEWE4 CONNEGYING,70 . ....... . BY . .:.� . . . ,�. . ..� . ... . . . • , ' ...• �;'�- 'PFIVATE DiSOOSAl5V5TEM �-' . . .�. , . � . . .. . . . � SI[Jnd1U�C � � CONNECTADDITIONAL6LDG,OR ,"���-� �` ����� `"� �OWNER BUILDER-DECLARATIOM '� ' ' '` - woeK ro House sewea ' � �'�� ` - � • •� WERFLOW SEEPAGE V:T,DRAINFIELD +: � I hereby aff rm rhat I am exempt�from the Coniractor's License ExTra..CE55Pool DRYWELL,MANHOLE � - Law�for ihe following reason(Sec�on 7031.5,B�sness ond Pro-. n�ieR.kEania OR aBANooN'HousE ""��� �� fB55iOn5 COfJe): � . � ' S'.W'eR OR DISPOSAL SVSTEM ' . � �.-..:. . . . . . .. . ....... . ...�,.. .....,. . . .. ....._.. ..._ � ❑ i,os owner of ihe property,or my�employees with wages as . . , .,fi ......_�_n.. ihei!�sole compensotion,will do the work and the shucture ., �o g e e? C �� is not ntended or offered for sple(Section 7044;Business - � � �� � � /; and�Profess�ons�Code). � �� �� �� � OWNER'S P@rmlt __5 j ` f/� "�, �„ ` _ " AUTHORIZATION TOTAL FEE � r ��✓ �. ❑ I,as owner of the propeity,am exclusively contractinq wHh� � °C ��.�'V licensed coMraciors fo consiruct.the ro ecf Section 7044, � wirH iH[HERFin ynnAE�CONrRACOR ro r�r.�(`u P I ( I HAVE A'THIS DATE A CONTRACT . � BUS nCSS anCl Pfof055 Ons CoCJe) � CON�ER THE A6OVE OESCRIBE EX:STING`JWELINGiO YHE PUBLIC;SFYrER.' � - � CONSTRUCTION LENDING AGENCY � � Ss� . � , •���✓C'."i G I hereby affirm Ihat fhere is a construction lendng�age ty -���� SIGNEDTNIS DAY .� 1 �� � for the� erformance of fhe wark for which this ermt� is �� owheaOk � � � P � � . -� P � OWNERS AGEM1T , . . �� issued.(Sec 3097,Civ.C.). . . . . . f, ...... '.:,. . ...� . �;.: � ...... , .,,. ._, . nooREsS ^ ," ' � Lender's Name �� ��� � . . � �,x� ,w+,s-,�-�..,Nz.re:.:�'^ ^r a�w*i=,.ia..��,p�ve�. . . . .;. ... ,�} ..nK .y Lender's��Address . . .� ;. ,..:, � .;.. �:;� _-.; . � .:.. . . '.�e . . . � �� _. . . ... .. .. ... . � . . . _ . .... .. ._.,. . ,.,. ... ._ . , I certify�ihat I have read.ihis�applimtion�d d state�tha�the , � -,� ., ,. �. �.. . _ ��� �.� -�:-� �obove informqtiqn is mrrect.J ogree�to co�rrip"ly with all Coumy �� � � � ordinances and�State Iqws�iegulating Plumbing and Sewers, � - � - � � � � � ��� -and hereby�autharize representatives of lhis Counly`to�enter � � � � - - �� � - � �� � � � - ��. � � � .��. u n t ,above-me ioned roperty for inspect on purposes � . r 9 !� O � (1-v�,���,.v._.., I _.. . �gnofu e of Perm i�e � Dqte � � � SEEREYERSE iOR EXPLANATORY LANGUAGE , .... ,,..�.:., , .:,,.., .,� '.�.•: .x, .;.,, ...�;... :,. •.<.::. .,,»n.r ..^r- �� . . .... � ..;.� mn. � , .. . .,,:, ..,...��'. x. ,. :. � o ,_:.. . . . :_ _ _ . ... � . . ..._:.:. , .:,, .., . .,. .,,.,,_ . ....:. ,,... :iYS9EG7C3R'i Pv°dYES .. .. .Q!^IT\�'$�Ii�L�s"f:�'.�I's��'.�LL'hRFi`I�I'L3I�i � .p . , ,,. .,�:, ..-. .� ,..:...... , ..,.,,.,.:�<w,.:w.. .,. ,......... . ... ,....--,�— ..._. .... ... ... _. ..... .__.. . .. . A$�f��Gy4rfr"++"�a j oaTe iNsa�croa�s s.,nr.T�ze �� � � �.��:E{t r i t�e s� a;.fram che Concraet�r's . . . — -- .—------- -----� .. Cewxousesew[q � � � � �� ixc iu L��- x ehe.clo�i x��asan fs.czs��a /03Z 5, n � � .. . � .,.. _ 6 _. .. .... . . ..,.....�3t', sq..ar F'< e rin,� .. 1 r,.n,� sty�nr- umtv . .. ... —_"@ ... . .. � � CNNECiAWITIOIJ.4l ' .��—_--�—. . . 6U:iDINGOR WORi( . ..... ... . . . . . ... . . . =� +.. �7d-�.. 6 .�i@S�:X i �<� G+"1s1.,4T..f,, kt.Zi� fPi�t�Le, ' SEGT!C'FhK.SEEP.°IT(5)'.,.. .. .--..— ..... .,.. . . . .. •. . • .. .. . . - !I»'O1.SK '+f j�4. .y t � RrG. . t„!5 ZT:.Cp. At�'D�ORDRAINFI_.D .. . . � - � ��.+u fE4fd8T�: .b3 �"c.�se ,t)>..ssC,J Des�:.o a�0 fTe a . . cssPooi❑ oavweu❑ __ . � ... . . .--- ..� _ ... .�..,.,. . .. _. ._. .. _ . .. .cr,f�`.s8¢te�� e.� tlat P..-s.. �vvex.s�d pursu¢nc Ln the , .. :�. . ':'_ . ... � �nv��i�:a.,of.`$2.,cs�trac 'r�s L%ce:ase._.�w f..SaQeer l ' aITER:R.PAIR,$EWER OR'�`� ' . . 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