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HomeMy WebLinkAboutNo Permit Number WORKERS'COMPENSATION DECLARATION � � I hereby affirm thot I hove a certificote of consant to :elf . _ . . insure,or a cerlifim�e of Workera'Compenso�ion Insurance,or �da6'ao . . _ . a cerrified copy thereof(Set.3800,lob C.) �F��RE°.a,B„ . -� � qpp��CATION�:FOR PERMIT � � Policy No. Company �s ' ❑Cer�ified copy is he�eby furnished. � � SEWER - SEWAGE DISPOSAL - � � ❑Certified copy�:f�led wtih�he counry bo�ld�ag��sPacr�o� � � - COUNTY OF LOS ANGELES BUILDING AND SAFETY deportment. Do�e Appikom FOR APPLICANT TO FILL IN �'¢ .��' CONNERION DATA . . CERTIFICA��NSAiION INSU ANCE RKERS' euuo�r� �y�g S• �'� ���. stnnor+ �(,�i8 t/ oerrH , AOORE55 ^7��7✓ .(This section need not be completed if the work involved by the � �(f'�"' ' MP.NHOIE REFERENCF /� �J,j� �+ � • permit is for one hundred dollars(SI00]or less.) ����TY �certif Ihot in Ihe rformonce of rhe work for which ihis ��ST � ���/ CQIi+��� � iv�a�W+�+cCT� �r�T"�x� Y PB CROSSST. [�✓���. Y. � CURB P.L �. M.L.iOP.I. �' permif is issued,I shall not employ ony person in any mannar .y�� P�� Q � ; so as ta b«ome subjacl to the Wo�keri Compenwtion Laws. a,�,NEa /��-Ey�F �Q��u'� CO.IMG.NO. lOB NO. Sp(� 0 , �,� ���/�•/]�2?y�� TRUNKGE4MITN0. ROA�PERMITNO. '[ Doie Applimnt � '`�REu ^.� . NOTICE TO APPIICANT: If, ofte� making this Certifitale of �� „��� TEi.eip. !�S¢D�OSO� ��'o�vit WAIV[R EASE�+�EM RKORD.�NSTR.NO. UATE O �mpfion, you should bemme subject to fhe Workers' //-� U , '.--�{npensalion pravisions of ihe Labor code.You muzt forthwith � pe5tki�vrqai�/� l0(NO. �'/ ` ' HWY.OR 5T.WIpENING �- �comply with suth provisians a this permit sholl be deemed �.�d3r A � � � revoked. e�orx rxncr 7 �� � $TAIE ENCRO�CNMEM � LICENSEO CONTRACTORS DKLARATION � no.pF p�ocs. / pfRMIT NO. I I hereby affirm thol l am licensed under provisions of Chupter SIZEOFlOT � NOW pftltOT ��J��ry$ �/_�` � 9(commencing with SeUion 7000)of Division 3 of the Busi- �ip� ��f �/{��9�� �/li�/�Q/� � � a�ac�s neas and Professions Code,oad my license is in full forte ond . �� �`�� 'n effect. ��Q _ coMawttOc w CONNECTION CMAPGE FEE .. LitenseNumber •� �v� lic.Clas�aj�'��� ADD4E55 ,�J �i-J6//� �.+y�/ 7 REIMBURSFMEM FEE Conlro��Or ""'"`r"�� �OI! �^/v�f�J ��7YV �/(qY(Y/J 7EL.N0. �� %� ��(:J, �ISiNICENO. GROUP MAP PROCESSf�BY � ❑I om e.empt under Sec. of the L.A.Co, i�Ns[rp. yV . a�ss G'� 3 �` � `'F��� (� � NO. DESCRIPTION OF WORIC f4E " PlumbingCodeand/or5ec. of�he FNA� {�A�I ATION - �y HOVSE SEN4F CONIJK'fING TO DAiE /Z PUBIIC SEWFR ���3/!j 8.8 P.Code for�he following reoson i�T��oA �� �a` . aits Ar+o.oe oen�r�IFitlo � DofG ' �5E gWyR CONNKTING TO ' BY . �� � VRIYATE Y iEM � $ignolUl! CONNECI ADDITIpNqL 9tpG,pR . � OWNER-BWtDER DECLARATION " W�To"Ws�s�w�R �� �� � =� � ?6 A WER OW SEEiP.GE RT,DRnMfiFlD - I hareby affirm tha�I am e�ampt from the Contracror's license FxTN.,CESSPOOI,d+�M'EtL MAr�HOIE � � �nw for 1he(ollowing reoson(Sedon 7031.5,Buisness and Pro• . xita,rse►�m oa neneioa��wuse - - -- � � - *�'• • ' '�� � . sions Code): s�v.Ea oR owos•i svsre�r, � . . � � -��,as ownwr ef�hn prnp.rrv m m�im•n951V11�!x,�yes.... . . . . I •`�'�v . �heir sole compensation,will doVthe work and the s�rudu�e , . �'� � is not intended or offered for wle(Section 7044,Bvsiness � - . .. . . �'�7"�`T ond Professions Code). OWNER'S Permit f �� 0 ❑I,as owner of rMe property,am exclusivaly contraUing wirh AUTHORIZATION TOTAL fEE � D P'.� f>—a`� � licensed controclors b consh�U the project(Secrion�044, I HAL[0.T iHiS DAiE A CONTRA�T WiiH iHE MEREIN NMAED CONiR4C10R i0 6usines5 ond Profassions Code�. � [ONNECT THE A80VE OESCN�BED E%�STING DWELLING 10 THE VU&iC SEWER. CONSTRUCiION IENDING AGENCY � � �6 �Q�'US ► • I heraby affirm fhallhere is a [onstruction lending agency �GNEDTHIS OF .1 _ � � - � � for the performanca of the work for which rhis permif is °N"'�Q� � owr+E �c,� �h'�' issued(Sac.3097,Civ.�C.). � ' � � - � - .. . onors�u ��— - S . __//�/hl�/ftj'_ Lender's Name - Lender's Address : � I cer�ify�hal I hove reod lhis opplicalion ond state IFat 7he �� obove informotion is cwred.I og�ee ro comply with oll County . � � ordinonces ond State lows reguloiing Plumbing and Sewers, � . � - - and hereby aurhoriz represenratives of�his CovMy to enler � . ' upon the v ned pr perly(or inspeclion purposes. . _ _ . 8�6—S� Sign t e of Pe iltee� �i__1)91���G,�, SEF REVERSE FOR E%HANAiORY LANGUAGF . /7'K+CJ • • s�g �� �� � Zr� �g 7 . . �T � DYi f.� . � Oza a�o ��j �� o f �_ . . ' -^: O z '�"..p, O O.. z,., x .. .. . • . ;�,T Z� ov ��O7 c�� c � __' , . . 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