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HomeMy WebLinkAbout1764A . ,. ,-- - __ ....... ..__. _�, ,; � . �,,. . . , . . , _.... ... .. ... . .::�.� _ , -:: ,... �.��- - WORKERS�COMPENSATION DEGLARATION � �� � � . �.� � . . -� � � � • ' - � I hereby�aifirm thot I have a�cenif�cnte-of consent ta seff ,:...... .. �, .�- � - - msure,�oro certifiwte of Workers'Compensation Insuronce,or � �6nafs�� . , ,tr y„„�„� ,„.„_,,,.... .� .,..-..-..---...� -._. ....,. . .......... ..... . ._. .. ..,» �.... ..,_ �.: . �:- LS � � a certified mpY theieof(Sec 3800 Lab C:) .. ... ... .. .. ce eosiue"v S�9i1 . `�� �' .�-.� � .. �s , /YI�1 ,,....;_...�........W...�...,,M--.:;;:�.,,......._._.._,. APPLfCATION �OI� ��it ; Policy No. Company .. .. ,. ,.:. r. .. , .. .,:.< .. _. . . SEW�Ft._SEWAGE�CS�St�d��L - ❑Ceriified ropy�is hereby fumished. . . . - - .... . � . - -� - ...-..- -_:--..:.� COUNTY OP LOS ANGELES� � BiTiIDING AND SAF�tY � ��M .' erufied,copy is filed with the county building inspection . � . department . . . �..... .._.. . _.. ,� ....._>. .. .. ........- . . _ _ 6ate` "" `Applica�i"` � _ , FOR APPUCANT TO FILL!N -?�1��L GONNECTION DATA , . . ,:a�.,,... .. . _ . .. , �ERTIFICATE bF EXE/v1PTIC5N��ROM"WORRET�5 . .. eviioihc �' �` ', 1 �� s;nrioN 3�- ,rr� oevTr+ � ' ' � ' -��- AODRE55 � 'CO/v�PENSAT10iJ�IN$U1�ANCE ' � � _ (7h s section need not be com leted f ihe work involved b the � A� nnaNHo�e aEFertENce '�J� � P Y � LCCALITY ..... .. _.� .. L WER permit is for one hundred dollars($700)or IE55.J ' ' , �"��� ' ' ' TYPEOFCONNECTION .,.�_. ... NEAGES� 1 IfNGTH FROM , , I certiFy that in the performonce of Ihe work for,which �his ceo555r. 7 ✓' � v. Cuke r. / M.�.TOP.i � . . ........ ._._.,.�. � permit is�iswed,I sholl not omploy anyperson in any�manner �� �� . Pc rvo: � '` > so`�da to become subject io ihe Workeis'Compensotion Laws. a.vNex � � 6� � � "`� co.i,ua.nq.� � �oe No,,,,,, ��7`� � :.,,,.. ._: � . , _: . ,.� ' . " . . .. , , ..:. ,,.- . n/Wll /p � ���}L• TRUNN PERMIT NO. - kOAO PERMIt NO. � �.^'. - Do�e � Applca t .. . � nooaese U I Y�-en. i!,'l `!s. �i . . _.._.__......_� __. ., - 9 �� AFFIDAVIT WPNER EASEMENT RECORD INSTR NO. DATE � NOTICE TO A�PLI�A"N7. lf,'afier ma�liing�th s Cedificate of �iTy TEI.r+o 6 � " � Exemptlon, you shovld become sobject to ihe Workers' . �EGAt �� ''� .-�Compensotion provisions of the Lobor code,you must forthwith oe5cx�,vrioN torn;a. Hwv.Ok sr.wioeNiNc �`"" ���� �"�comply witF su<h provisions or this permit shall be deemed � — �J� � � � ���-���-���'--""'� ' " ' � IEVOIted. ,. . .. .. : . BIOCK TRACi . � ^ PERMIENO. ACHMENT :.. . . ....,..2.s . ... :._. NO.OF BlCGS. ' . .... �-� UCENSED�-CONI'RACTORS tlECCARAT10N D � � � � SiZEOF LOi� Q � NOVI O«LOT ,.. �.... : ..... ... . . .. � I hereby affirm that I om�icensed onder provisians of Chapter� . - use oF � ° ` - � / � - �-��� '"�"�"'��"" - 9(commencmg with Seclion 7000Jof�Division 3 of ihe�8usi- eunoiNcs� .- k L.. `ei d`<'E^GN ci+n�s - ���� �� - ness�'and Professions Code,and my license is in full force ond r . .� - - - � . CfFe,Ct. ' _. , . . ... . , CONTRACTOR 't �y( CONNECiION CHARGE FEE LiC8n5BNUmbC LIC CI�55 qDORESS 9 ' EIM6l1R5EMEN EE� � ,�,,, R iF ' CO�1�aCtCY ��::� rv':�D01C• ... � �•. , • . IJ ��^ `�I C �ISTRICTt�O. GROUP ' MAP. . . PROCESSEDBY'A.... CRv y� TEL.NO. / l 7 .. .. . { g- BK . PG / . ❑I am�exempr under Sec af the L.A.Co STCENSE h�. /! J S � cin5s G�^ � �t� J�� � �.¢ �4� Plumb ng Code and/o�Sec- � � ���of fhe � � No. DE CRIPTION OF WORK FEE .. . .-.. - p�uq � ' � - . �ousEseweRcoNNecriN�ro � �� �A�e �y,� � VALI ATION , . � . ...... .. . ... ...��......� FU6uC SENER ...... . .. B�.&�P Code for-ihe followin9 reason s�cnc rnNK,seePn�e P�.L oa., ,. . - '� ��.' �...% • :� . . :�: .. ... oitSAND!ORC1kA1NCIELD ...... .:.. . FINAI . - ��e HOUSE SFWER CONNECTiIvG TO � � � � gY ,':- , .'. ;�;' • �.;... , . �'' . . .� � Pk!VATE DIS?OSAL SYSTEM... $�QnafUre � ..-.�- C(]NNECTA.DOIiONAl6LDG.OR ,' �'� � . � . .. -...�. • YORKTOHCUi SEWER . . - OV✓NER•BUIL�ER-D��LARAT(ON -�� �� � t �/S.�;1 . ' ,; . , . .. �� OVERFLOw SEEC�GE P�T,-DRA,INFIELD . ,,, � I hereby affirm�ihat I am exempi from the Contrac�or's License arv,.tssaba�oe�we!L NaNHoie� -"_ " � � Low tor ihe following reason(SCC�Of1 7O3�.S,BUISl1C55 aI1CJ PfD- AiTER,REPAiR OQ ABANpON HOUSE _ ' . � , � n � SEWER OR DISP(iSAL SVSTE,Vi- �� ��� ° p ' �. � fessions Code): , - ... �. � ,. . . .. . ,,. �. ❑ I,os owner of the.property,or my em,ployees with wages os � r � '�'"'V � �. thefr sole compensation,will do Ihe work and the structure is�noi intended or offered for sole(Section 7044,Bvsiness � OWNER�$ Permit ..s ,�t`� 5 T � - ��� ���'�J v � � � O i nd Professions Code). � AUTHORIZATION TOTAL FEE ��'.+/% �;,,v�a G 2 ,05 owner o41he pioperly,am exd�sVvely conlrpcting wrth . . . I�censed contractars to construct the PfO�ECi($CCtiOn 7�4Q, � � i HAVE Ai THiS DATE A CONYRAtT�WITH TNE-HEREIN NAMEC CON ACTOR.,TC, ' BUslrl@SS anC{Pro�e55lon5 COCIE) ' CONNER THE ABOVF DESCR� "'ERfSTING DWEYYI�YZ`i.'16 YFTc"'7TJ9'.1�'?�4ER�� . . . . . ...,. ....,. . . ' �' CONSTRUC710NLEN6INGAGENCY -- ��� � � v � �" �' , . I herekiy�affirm that there is a cansiruction lending agency � - SIGNE�THIS �A` F �p 7 . ' .for ihe erformance of the work for which this ermt is OwNe�oa P P OWNERSAGEM issued(Sec.3097,Civ.C.j. � � f e . � ... . . �. . . _, . . . .� nooa<<s . ",. Lender's�Name . . . .;.. ... . . . ... �.. .. . . .,.... ._ . . .. . ., .. .. , . ..,�.... _.. . � .. Lender's�Address.. . �..�.:, :_.,, ..... . � _. ..,.,. ........,�.., ....,. .....�._ ...:........ . .....__.._........_..__._._ ..._ ....._..._.._..,. .._. _.._..._ _._.__..____..._.._. ... . ,...... .____.... ,_,.,.. � I certify�that�I have read this applicarion and state rha�the � � .. . � � obove infocmation is correct.I agree to mmply wiih all County . . . . . _ . � � . _ � � .-orrlinances�and State laws regulating Plumbing and Seviers, � � � _ � � � � � �� � -'and here6y authorize represenfatives of fhis County to eNer - - . . � - � u'�,p�n��t j�abo�e-m/entioned properly for inspection purposes. � � �� � '1! /` // � x�i6 L �J'�'J� , . . .... .. . . :. �. .�.::.�. _. t,..�_�. . _. . ._. . _... ,. ._..., . . ���� � SEEREVER5EFOR�XPLANATD�VLANGUX�GE �� '��� � ���� � :Signatur of Permi�e Date � .. . � � . � � �...:- . . �... � �. � �1: ...� ,; , .. , .. -�.:'. � .. '.z..A �'�i: -:.: .:. ,. -- - � .:�.i.., ....::�h . . ,� - .s.'��....:_�. ,.,:':.. �:'�. '., .,s.�:.�!._.,n.. .'-..�r-, . . ' ��1�4F ' ' S.w�wie.n.�+�4n�'��+ac•r _ _ _ _ , _.._ .____— _. �h�:������ d.A�;�s .,,._. �:,.:�r . . . , : _�. ,��.�T_ '��'�iY�.����73����`t x.3�C�A'i2t�Th�N... . . . . .. . _, ; :>�.. . :,� ,:�. :,: .. .. �. ,,- �v,. , ��y�a�(�bp'�yTy. .. �are it�sFecroa's s�+�nruR.. .. . . . . . . . . ".c-ebg atnr,n t't;ae�axn ez_mpi fxort th�i;or.traror'c , � - �?,itens�E-aF•Enr.hc�-:n-f ssrtrF'.reasr,n(3e<tina 7p31.5. � . .... . . ....-„ ,...,. . :,.. . . � NEwHous=SEwea .. . , �... _ . �. . .... .. ..,,�; � . , r3wslr.ess.aad,Prefcssu. c,n�:a): lzny..=cty or�r.ci?rsty CONNECTFpOIiIONAI �. T . �. Y . t [ L '. . � bi f �G' �r t - �o2F M29Y0'2 - 9UiLC1uG OR wOac �' � _. . � - , p �c ra s .ccCu�z ^�a S•d c, urce, _ ._— . .. . . . - . ____. O sevnc TnnK,seea,-crt�s� . . . .. _�. ::- .. .. ._:•.. _. ,.: l a ..q_i a EAe a;� . . f � AND/ORDRA!NFIELD ��� � ���� � � � � ' " ' ' �- " -' � Q �L 8 LT�6t I'i '�C^n3E�fX1T514f'ty201tFJC —.._ CESSPOOL❑ DRYWELL❑ .. . , .� . .. —' � _____ 6'Le _�6 C � ...' . . � � .. -. �— I ... ... , . . . �rnvzz1�a�c � �e C ztt osb�7�,�t;l rsj`�L�.�uso Cbanr�t,he ' ALiER,'REPAIR.SEWER OR �- .. ' .. :.,_�,�_ �„�,,,,,_q.. v.,o,,,�... � sEwn�[oisvosni sv EM 1��� �� , . �: ---'— "- '� "" ' ' 8u en ss��. 3 P �...cns Cr2ef n �e�e he s oxempt . �iiCGNN c ttu�nnio � I � 7 � �� � � tF er�>cr.a aad Enr An+3 j r�alle�{erl er.a�ts�a.Any nar,�,00u Heuse sEwe� � ...�� � ' ol.na�r�f S rcxc �1 S d pJrcw -� 't . saa a 5 rie'anes p .. ' . , � . - �,� y,�jects thc c.7fhr�cz�: o a cw nully�c;Mo.ar.o BCEb¢n � SEEP PIT )C CC55 OOl L�'. _ ..— - _ . � ,�.�- , ,•,�.•_,-^-� ..,,;:_ ,.. . - "; . �fsve�Fiunr:+�ed aal3urs/� �s�Jl ... : .% � '�^ a .., �.__.;. t-.:.�.". .. �-- � - of.;rps d : ,.., — . �. .. � '� ' - ng ' . ........ ....... _�.. . . ..._. ., ..._.. _..:: ..., . . ._ ..[]I:-a.,.i:eor�ner ppvrtymits.dc:;5ewa-k�an ,. . .., ,,• ..,. . . , : � .. ... .' -' ... ._ . . . . ..: .. . �. �' . -. ;.,:s. r� �,;,�. ,,;..� . �.., ` ...: :� ehc s:ruczure__��not iniecdvd ci;�oH�:ed for�s..Ia� .. �� - - ... . -. ..._...,� . ..;,.,. � . . � . _ .. , . . .. . . ' . .,. .. ,. .:�. - . • . ._ __:_ .._...__._ ....:.;...___ .._. . :..._.� .� :.. . .. , .' :�.. (Se�.� IC-44 BN36n,P53 a:ed Profes3caszs Code. T3¢�Cnn- ; .. . . . �. _. ..,.. .•.,.•. ...:.' „�_..., . �..'.� a_�c..,': er.,...T%�aei`dnes nr,i��e,31�1y Cn ax a"uxscr-of � �. � ....... ............... .... _ .:.. .. .... ......�'' ! ..�. �•�• , . . . � ..,,... 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