Loading...
HomeMy WebLinkAboutNo Permit Number (48) WORKERS'COMPENSATION DECLARATION � � � A ' I hareby affirm that I have a certificata of consent �o self ��7p � 1s � insure,or o ce�tifitole o/Workers'Compenwtian Insurance,or °`°";',�`oPy'""'o"�`.'e°°,`ob`, "�`R`�.B,", qppLICATION F4R PERMIT Polity No. Compony 0i i ❑ce,,;,;�a�,vY,s hs,sby,�,�;,n�a. SEWER - SEWAGE DISPOSAL ❑Cer+ified copy is f�led�+��h+he counry buitding inspec�ion • COUNTY OF L05 ANGELES BUIIDING AND SAPETY � departmenl. - � � � � oar� ApplicoN FOR APPLICANT TO FILL IN / f _ �3 CONNECTION DATA CERTIFICA7E OF EICEMPTION FROM WORKERS' euuw�c �I f� LEINON t-�C SuraN l�� 0 oevTH / � COMVENSATION INSURANCE .+mitEss 'Y J (This settion need nol ba compleled if�he work involved by the �/ G/7" , �up�t�FEa�r�c� p,�3/ ` a � � -permil is for one hundred doliors(E100)Or less.) � - ���� I certify that in the performance of the wwk for which this c�sr. �7L� CQ'-/M/� nPEOFCON"K��O" �"w�"�'. � ' r. cuae i. M.�.To v.�. } pe�mit is iasued.I thall not employ ony penon in ony monner y�a��'^' �f /�f P.c.�. � O so as ro bacome wbject�o�he Workars'Compensa�ion laws. ow�a /�'-�-"'�T �F .�c �,�y�.fF. � to.u�na.r�o. �pe r.p. V - - �'� ��•LC/X z20�'� TRUNK VFRMIi NO: ROAD PERMIT NO. � Dale Appliconl • nDDRES..` NOTICE TO AVPLIGANT: If� OE}Of makin 1{li5 �C��1{ICOIB D{� � ARIDFYIT WAIVER EPSEMENT RECORO.INS7R.NO. DATE 0 9. ��, ,er �TF�.�.�i�f 5�0�..GY� � ption, you should become s�bject to the Worka�s' i�� � �U —�` u _ pensalion provisions of tha Lo6or code,yoo must forthwith cesca�vr�po���or r�o.- - Hwr,oa st.�vnoer+ine . a � tomply with such pravisions or this permit sholl be deemed p/' y fOVOkBfJ. - BIOCK TRAC7 07��� S/AlE ENCROACHMENT Z UCENSED CONTRACTORS DECLARATION r�o,a e�o�a veRxuT rq' . 512E OF LOT, NOW ON LOi g ' I hereby offirm iho�I om licensad undar provisions o(Chop�e` �� AM �/ ���i�/y/• o�f,l�� � � 9(tommenti�g with Section 7000)of Division 3 of the Busi- eunonaG5/UFfit/ �/�/��F+�f�%�/�y /77�� p���s . ness and P�ofessions Code,ond my license is in full force ond ��,L`, �/,K � effeci. ���j�� eor+taneroc in1l �v� r eo'+�+eeriou weac�� � license Numba�-�"��w' tic.Clau C�� � BZZ¢ �E• /Iry,'��/�'/I. /�hJ^' qpp�s5 REIMBVRSEMENT iEF COn�1OC10f„-"'ry� DOI! ���7 FJ J CIIY .� (rt(/(�%j�� 7EL.N0.//f �8/��T�/ O4TRiCI NO. GROVo MAP VROCESSED BY �, ' ❑I am exempt under Sac. of rhe L.A.Co. �A�� ���� ��,�� 4o R.��- .� a �3 �%iyi� � � NO. DESLRIpf10N OF WORK HE � ' � PlumbingCodeand/or5ec. ofthe F�� � �//��I ATION &K SF4�VEA CONNFCTING TO ' DATE ///Z3�} ' . B.8 P.Code for the following.eason p�K TANK,SEEGAGE qT OR �� � � PITS AND/Oi OWINFIFID FINAI � . �o1e �q{)g SEyyER CONNECTING TO . Bv ' � ' PRIVAT DISPOSIL SYSTEM . . $i9nOtufe - COH7ECf ADDITIONAL&OG.OR � OWNER-BUIIDER DEClARA710N � woc�c ro'au5[s�wEp � . . � I hereb affirm rhar I am exem i from iha Contractor's License ���OW SEEPAGE PIT,DRAINfIFID � Y P ExiN.CEsSPapt,qtYN'Ell,MANHOLE . . law for the following reason(SeNon 7031.5,Buisness and Pro- uhR,a�r,.�zoa neewaa Noust - � - �..,�ioas Code): s�wea«e o�so�osn�srsnrn �I 1 2 3 A � oscw•;�,��•��p:cpe.'•,•,c:�^ycmp!oyeaswi•�v:c-y�scs � � . their sole compensation,will do the work and tbe structure � +�`. � .v� (1 is not inlended or offered for wle(Section 7044,Business �� � -- � - ; ond Profess�ans Code). OWNER'S PBrmit f � � � �2�j� ❑I,as owner of�he property,am exclusively contrac�ing wilh AUTHORIZATION TOTAL FEE � � � ' ' � : licensed contractors�o construc�tbe Plo�e[f(SeC�i00 7044. I HAVE AT h115 DATE A CONT4�CT WITH TIIE HEHIN NAME�CpVTYwppR i0 • " •2 7.5�_ Business and Profezsions Code). cor+nea n��eove oescaieeo exisnn�owewr�io TNc Pueuc sewtR.� �- ', CONSTRURION LENDING AGENCY - C , O b,1 b-�3 � heroby affirm ihat Ihere is a conzlrutlion lending agency SIGNED THIS � Of_ ���`�'�- I _ - �- . � for the performance of ihe work for which this pe�mit is o°�NEa , - ', issued(Sec.3097.CiV.C.�. OWNE N[ � . ADDRESS Lender's Nome � � ' Lender's Address � ' . ' I certify fhai I have read this opptitotion ond sto�e thot tbe . � - � � - - � . . obove information is correcf.I agree fo comply wi�h all Coun�y . - � � � . .. ordinances and Slale laws requta�ing Plumbing ond Sewers, � � � . . . . and heieby authoriz presentatives of this County�o en�er � . . upon " ned prop ty for inspection purposes. � � � �r/��v� . ._ _.. .. . . Sig ure of P�e � J ���1ot�, � � SEE REVfRSE fOR EX/IANATORY UNGUAGE , _ � � �il.�A�/�el , i mg M ' � 'A v v�t+4 M � ��' Zm � � _ . M f� Yn Y?� $ pq Gi� N 'O � � ' � :. 1'i� �n,�o., ctZ., O V �, 'O y^� � }y r � ' . . N N �-L� y�D " N �O �.. O , i` '" 's� $'° Q 7'^o s+4y � � . ' . �� Ov v,T • `.:. �cr � , . a i'�C �� O �=� _• . ' c�v ✓;v <p *.'5 � V� ' 2 � � . , � �� �� m ai `r. � . . . g0 A i � � . . ' . . � � ` ' N . O ' . - ^ . , � . � ' . . ' . . 1, j . � 1 • A ` , ' Vn �� � . . � . . . ' � � p ' ' A . � . . ' , . Z . N , . . � '.` y , �. . . . . � , � � � � .� , - ' ' , � '�., ' , �! � . . . .. . .. . . �.,'. � � � N . , � �� j ' ' •J. � ' ,' %;� ../ � J , �. Z i: � . • O ' / r i, � N ' 1 . . - . � i' • r ,♦ ` '� ✓ i . .!- . . " � , .. , . � , v �, , ' "r . 'l. - '.: , . . � _ .. . ;� �- '•� :r � , � . �, � :�:' � . �.4 := t"+n �`'�'•� f. � r �.�o o'3 0 o y � „� � . `�`F' O",1`+� v'"3 N i�.: �n K � Ii. 7 ' . .� N w.�� 1 C1��Q l��4��h � �C N�.�. N i . � �. c. � i'�. .. � S y K .. � � r r•.^'^�„ �p'G �:, � N ^:. C.t, f ^ . '� w q �.� K' v� Y .1 .i•'"`M n � `, ��,r,C,...t � M�� i�' F.^�"O �y'3 r `-O...". �� '� i: n+ � 1�+, . . � . � ✓'. "''� •- �y;'»� ': �G �n �'~7 G-� " � ^.� c '? r. � C. � � ' ..r�. �� � :.:�. �C ^..� fi L...t„� ��-w.�-'_ . r� "" `=�. � ' . . . . , .� Jt+ S=. �,....0 _:..T.F„ _ t� p,G,,,;�Y,^. � „ ti� » L y„"' '"^ n � � �,t _ • . • � O v `v r' n� ��^ �,'• �v� »' � � o �c, N" o'--...-A_ ti ..O �'' . . .� y .. �. � .. � �, �' �' .A.s.�_ ... . � .. . . . r <;� c Mio�� c..` �N .�,� ,,,,� "o«..`c::� -..i.u '. ° n �'�, - ' ° �' �� " ; _ - �-� � � ��o ��:� � ��� »ro �.:;; G . .. . , '� M r+• '�� �'. =��. O F' �f� . G " O �' �, •`5,,,'7� rr1 . . . , "� c K: .. - ,1 � tc n O A v��t (� N, � � ^o „ ..- � ' . � . �, O r . �x-.r�c �. � �..L:� `=.c-^.,° o "'� M`r •'" n . . • r` � �*��,�:- ., N �„ .. �,� �. �'o r� �=• G " T' ... .. ' . . �� C, C�. �� y v C f .C. � L.y�n N.�R! � 3� �1 r ' . n yi (3 \.���, �.ti-C..C ^.�..,, . V ^;y n�y'�' -�^..�.`� r. .� . . ; .''i - M rt , S-'_ �-••,,, N ., C� Q:�a ^ � t"" :; V�7 ' �.. . N �' F� " '�'� i .^..'�c o��. v�:..�-:.`� �� � ° �"' 'o o �� ,�i .. �^y n %��� � n o n�o �s. F. �o£ �a = ; y?, O . 1 . . . . , _ . n • C .i a 0 .� �:..,"�.n Y�r �' �•,� �` .� .� . .. . . . :�'`� C C� ✓ c�^,' �'.. C 'r 4 C w n ' •r " • p p ., tn C+ ,+r s� �" 4 ,�j c y � r O� �r. � •. ''i7 � � O R7 C-.} �`;� � �"y O n•'^t� ..� t' � n Y�a � � �� "l ... 4 O 2 .N "'4 ... Vi . `' �.� � �� �E, � �F n » � �bLr�pm s' � o '/��. � � . . . t. n n P� 4 �•v o . ".. . . . . �. , o�A � �.0.� . � � ^ ,, � �� �.� N� � . . . . •` e tiOti n ��, '�� , ' . . . �� �1 . .,: , - . ' , � �' . - � ' ' �� '