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HomeMy WebLinkAbout1764A (10) . _.,. .,_ _� - _ ....... ..__. . . �,,. ,. . � .. ,,,� ,.,. ,.- ....:�,� _.. , ,_ . �.. . .. , �.��-. �.,-�-.. �_Y._ ... ... - WORKERS�COMPENSATION DEGLARATION � �� � , . � . . -�� � � � • ' - �� I hereby�offirm ihot I have a�cenificnte�of consent to seif :...... .. �... . . � - � msure,�oro certifitate of Workers'Compensation Insuronce,or � �6nafs�� . r y„„�„_� ,„.„_.,.... ,,,.,,..,,.,�...--....� -._-. ,.. ....,. . ....... . ... .. . . �_.� ... � .. � � a cer+ified mpy rhe�eof(Sec 3800 Lab C.) � -�� ��� �� �� ce eos�ue'v S�9iY � �� '� `�� �' �s , /YI�1.3....;_...�........W...,....,,�--.:;;��.,,......._._.._,. .APPLfCAT{ON �OI� ��I� ;� - Policy No. Company -. ,. . . .. -� '� . .. .. . SEW�I� _SEWAGE�C��S����iL .. < _. . . � � ❑Cer�ified ropy�is hereby fumished. . . . - - .... . - - - ...-..- --:--..- � COUNTY OP LOS ANGELES � BiTiIDING AND 5AF�TY � ���� .' ertified,mpy�s filed with the county building inspection . � . deparrment . . . �..._ .._... ,.,.. . _.. ,�, . ..,.:._�. .w .. _.......- . 6ate` "" `Applica�i"` `� _ , FOR APPLICANT TO FILL!N -?�1��L. GONNECTION DATA . . : a�.,,... . . _ . .. ,_.. __. , CERTIFICATE t7F EXEMPTIdN��ROM"�WORRET�5 . ... eviioihc �' �` ', 1 s;nr,oN ��- ,�r� oerTr+ � � � ' ....' 'CO/v�PENSAT10iJ�IN$UFFANCE -��- nooaess � ��� � � � ':. (Th s section need not be com leted if the work involved b the � A� nnaNHo�e aeFertENce 'f J� � P Y � LCCALITY ..... . _.� .. L WER permit is for one hundred�_dollars($700)or less.) � . ������ � � " TrvEOFCONrxcTiora� �..:. .. NEACES� 1 IfNGTH FROM , , I ce.tify that n rhe performonce of rhe work for,which �his ceo55sr. 7 ✓' � v. cuke r. .� M.�.TOP.i � . . ........ _._.,.�. � permit is�iswed,I sholl not omploy anyperson in anymanner �� �� . 'y P�Np. � '� � so 03 to become 5ubject io the Workeis'Compensat�on Laws. a.vNex � ,/ 6� � � "-� co.i.+nv.nio.� �oe No,,,,,, ���`� u . '•..'.. .:... �: . , ..: � ,.- . MAII /p {"�'��?L• TRUNN PERMIi NO. .. .. kOAO PERMIt NO. � �^'. - Do�e � Applicani .. _ �- nooa¢sf U I Y�-et. J!,'L `lsap f!' i . . ...__._......_� __. ., . . „ .,,,.�,„, ,.,,,,,..-_,. ' ' p �d p AFFIDAVIT WPNER EASEMENT RECORD INSTR.NO. DATE � NOTICE TO A�PLI�A"N7 �lf��afier ma�liing this�Ce tificate of �iry TEL.r+o / / / 6 � " Exemptlon, you shovld become sobjecl to Ihe VJorkers' . �¢Gnt �� '''� .-�Compensotion provisions of the Lobor code,you must forthwith oescx�,vrioN � torn;o. Hwv.Ok 51.wioeNiNc �"" ����� �"�comply witF su<h provisions or this permit shall be deemed � — � � � ������-��"'��"""�'�' " � �eV�ked. ,. . .. .. : , BIOCK TFACi . � �. PERMIT NO. ACHMfNT .:.. . ....,.2._ . .... :._. NO.OF BlCGS. . LL � �-� UCENSED�-CONI'RACTORStlECCARAT10N QD(') � � � SiZEC�lOT� NOW C��LOT ... ,.... : ..... ... . .. � I hereby affirm thot I om�icensed onder provisians of Chapter� . - use oF � ° ` - "� / � � �- ��� '"""'��"'" �� �9(<ommnncmg with Seclion 7000Jof�Division 3 of ihe�8usi- sunoiNcs� .- k L- `ei d`<'E^GN ci+n�s - ���� �� � ness'and Professions Code,ond my Iicense Is in full force ond r . .� - - - � � . Cf{e,Ct. ' .. , ... ... . , CONTRACTOR '� �y( CONNECiION CHARGE FEE liCenSB NUmI)C LIC CIa55 qDORESS 9 1 ' REIM6l1R5EMENi FEE� � ,�_, ' C0�1lOCtOY ��::� rv':�D01C• .... •� :•. '/ I� �)^ "I C �ISTRICT t�0. GROUP ' MAP. . . PROC{SSED BY'A.... C�TY y� 1EL.NO. /� / J �/ .. .. . { {' -} • /}' BK . FG /q' / . ❑I am�exemp�under Sec af the�.A.Co STc NSE n0. f! J � L-. CLnSs G�� � �`E t� ��' � j��✓ �'�� Plumb ng Code and/o�Sec- � � �� of fhe No. DE CRIPTION OF WORK FEE .. . ..�. Fiun� '. ' . ._. . � ' . h'OUSE SEVJER CONNECTING TO �� �ys y�y DATE �� �VALI ATION .. ... ..... . ..�. ..��.:.... FUEIICSENER .. Y �' ...... . .. B�.&�P Code for-ihe followin9 reason � ' secncrnNK,seePn�e r�.Loa., ,.. . - ��.' �...% . :� . . :�: .. ... oitSANp/ORC1kA1NCIELD ...... .:.. . FINAL . .� � DD�e HOUSE SfWER CONNECTiNG TO � � � � gV ..:- , .' . :�:� ,' '.;... , . '..: • .... � Pk!VATE DIS?OSAL SYSIEM... $i9rlafUre � ..-�- C(]NNEC�A7�IiO�AI 6LDG.OR _' �'� � � . .. ..... . . ......... YORKTOH lli SEWER . . - OWNER-BUIL�ER D��LI(kATT01J oveaFiow 5e=c�Ge pr,-oaA,iNFiEto . .,. . � ����''� � I hereby�`affirm�ihat I am exempt from the Contrac�or's License xrv,�ssabo�ov we!L NaNHo[e� ��� � Low tor ihe following reason(SCC�OfI 7O3�.S,BUISl1C55 OI1CJ PfD- AiTER,REPAiR OR ABANpON HOUSE . ' .__ � t. , ; �. SEWER OR DISP(iSAL SYSTE,Vi� ��� e p � fessions Code): , � ... �. � T ,. . .. . ,.. � ❑ I,os owner o4 the properly,or my em,ployees with wages os . r " o� f,�V � . their sole compensation,will do Ihe work and ihe structure is�no�iroended or offered for sole(Section 704�4,Bosiness � � . ° r �� �-'�J� � � � O i nd Professions Code).� � � � OWNER'S Permit �.S ,�t'/ S T . .V AUTHORIZATION "� - l "�`. -' ,05 owner of ihe pioperry,pm exclus{vely conlrpding wrrh .TOTAL PEE �:�// . ��%�—G� � I�censed contractars to construct the pro�ect(SCCtiO�7�4Q, � � i HAVE Ai THiS DATE A CONYRAt'f�WITH TNE-HFREIN NAMEC CON ACTOR.,TC, ' �USine55 anc(Profe551on5 COde) ' CONNER THE ABOVE DESCR� "'ERfSTING DWEtYlA1Z`,_T'6'YFTp'M79'.1�'$FS4ER' . . . . . ....,. ....,. . . ' �' CONSTRUCTIONLEN6INGAGENCY -- ��� � �y v t- {�' � , I here6y affirm that there is a consiruction lending agency � - SIGNE�THIS �A F �p 7 . ' .for ihe erformance of the work for which th�s ermt is OwNe�oa � P P OWNERSAGEM . issued(Sec.3097,Civ.C:j. � � . f e . � ... . . _ . . ...' . . . .� ADDRccs r ��. . � Lender's�Name . . . .;.. ... . . .. . . .,.... ._ . . .. . ., .. .. , . ..,.... _.. . � .. Lender's�Address.. . �..�.:, :_.,, _.... . � _. ,.:..,... ..._........, ....,. ....�._ ...:........ ........_..._........_..__._._..._ ........_.._.,. ._.. ....__....�._.__...__.._.__.._..... .. . ,...... .____.... ,_.. � I certify�that�I have read this applicarion and state rha�the � � ., . � � � above infor.mation is correct.I agree to mmply wiih oll County . . . . _ . � � . _ � � -ordinances�ond Stafe laws regulating Plumbing and 5eviers, � � � � � � � � �� � -'and here6y authorize repreeenfatives of fhis County to eNer - - . . � � � u n �abo�e-mentioned properly for inspection purposes. � � ��,� /1 � x.� ��� �� _ .. _ __ . ��� SEEREVER5EFOREXPLdNATD�VLANGU%�GE �� '��� '��� � :Signatur of Permi fee Date � .. . � " . � ' � ��,: ._� ,._ � .:�.i.. ..�..:_�h - .. '...: . . ,�,.A c.t.�:..- _�:• ':., .,.y.�:.�._..v..,:� . ...'-..-�+i. ,i'��....:n. . ,.,:':.. ,��, 1�M4F. •, . :.S.w�wti:.w--�R+*�n:n'n�'�.:.,�c•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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