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HomeMy WebLinkAbout1268A ��� WORKERS'COMPENSATION DECkARATiON � I hereby affirm lhat I hava a cerlificota of conseM to Self insure,or p certificota af Workers'Compensation Insurance,or �ene+2o , OCeY����'��'��`mp��remont IIIdEIILT1I-ty ��IREV.B/81) � �ppl(CATION FOR PERMIT rar� . p Certified copy b hereby fornished. SEWER - SEWAGE.DISPOSAL ` . - ��Certified copy is filed wi�h the county ilding inspectio � COUhTY dF LOS ANGEIES BUILDING AND SAF�TY department. oo�a�'�1___�__R�pplicanl F�R APPLICANT TO FIlL IN CONNECTtON DATA CERTIFICATE OF EXEMPTION FROM WORKERS' g�µp�� � � _ COMPENSATION INSURANCE aoouess S�O �S SrAT�r+ oEvt� . .. . . ...-- (Tbis section need not be complated if tbe work involved by the - - - --- - . : - - . .... . . ... .. u�a permFl rs for ona kur�ed do}lan�$700)«iess.j iouu itv - ++oie Rcr�a[Nc[ �. _ ...�owee M4N . . . . . .._........_._... .... .. .. . . ...__ .. . . NFnRESf� Old....._........ .......... .. .. . .. ..... TYPEOFCONNECf1ON. . .. .._. ...... . 1 certify that in the performance of the wwk for which this CRO555T. IENGTNFiOM Y. CURB V.l M.L.TO P.l. permit is�ssued,l shall ndt employ any persort in ony mpnnar � � ' 'I''he Anden �Group P��-^�- so as to 6ecome s�bjed to Ihe Workers'Compensation Laws. pW�R co�tiv.r�o. ioe uo. � . ' . - ' hV111- ' " - ' TRUNK fERMIT Np ROAO PERM17 NO. Dote Applimnt /+DDRE55 � ?ICE TO APPLICANi: If, offer making tf113 Cerfifico�e of ��TY AfF10.4VIT WA:VER EASEMENT RECARD.INSTR.NO. DATE _mption, �you should become s�bjacr to the Worken' Compenwfion provisions of the tnbor code,you musl forlhwi/h � pEscpt i�iori irn*m� MWY.Ofl ST.WIOENING comply with such provistnna e��hFs permit Shni4 oe deemed 42586 � �eVtlltGfl. - - -- &OCK TRACT� STAiEENCROACNAAENi —'���5 PFRMIi NQ 4 110ENSED CONTHACTORS DECLARAIION size or ioT Now oN�oT � 1 hereby offirm ihat 1 am licenaed under provisiona af Chaptar �� . 9(commencing with Section 7QOQ}of Divisian 3 of ihe 8usi- suuoir�s cHnac�s , ness and Professions Code,and my ficense is in fult force ond Qffe��� '- -- ppNTRACTOR CONNECTIONCMARGEfEE } . - �li@CIS@NlllllbEf._____..Z��J.ILL�QS4__. - _ d ��6---- -- - Aoo�--12385-�4a nfl�ia Av�.-- _ --- ��Ms���. __ _ _ _ _- --- - -- p- DISTRICT Np. GROUP MAV PRIX'FSSED BY V Controc�l:R PLITMRII3CiDa�e7J31�8Fi ��iy Riverside iE�.,�.��1-5oao � � Z 0 1 am esempf undeo5oc. . of fhe LA.Co. iiAccnsE No. cinss 1� 0 H Plum6ing Code and/or Sec. oi 1he �� DESCRI K FEE - �E� U _ HOUSE SFwER CONNECtING TO W WBLIf SEWER f t../,..$L B.8 P.Code for the foilowing reason � V ALID ON � $EFfIC FANK,SEEVAGE PIT OR P�TS AND/OR DRAINFIELD fINAL � ��� MOUSE SEWER CDNNECTING TO g� PRIVAi �ISPOSAL SVSTEM $19n4fVlB [pryryECT qppR�OpJF[6lDG.(N7 " � ONINER-BUftDER-DECtARAT10N - w°aK�oNWs�''E'^'ER OVERFLOW$EEPA(�PIT,ORAINF{ElD � ��ereby affirm that I am exempt from the Contractor's license EXTN,CESSPO�L DAYWELL,MANHOIE _; �`�µ . . . . ....:.; for the fol(owing reason(Setton 703L5�Bu150@33 OfIfI P�O- AL7ER,REPAIR OR ABAN�ON IqiJ$E, ' ' ' _ , - ..,sionsCode): ' . . .. sewcaarasrosaisrsrtm.. . � .� ._ .. x, .. . ._.. ... .. .. . -�- - - -- .. .... . . . . . . . . ❑I,as owner of 1he property,or my empfayees witfi woges as ti' 6�`��� G iheir sale mmpensolion,will da ihe tvark nnd the strucfure - � x �L� - �is not infended or offared for sale(Sactian 7044,Business "�� and Professions Code}. OWNER'S Permil S (? Q ❑i,as owner of the properry,am exclusive[y tontracting with AUTHORIZATION 70iA1 FEE - � � _. �' "" e- !.'���" �icensBd conhOLtors to'Wnsiruct ihe projeCi($eCtion 7�44, I HAVE A7 THIS DATE A CONTRACf WITH 7HE MEREIN NAMEo CANiRAC70N TO 7i C'(_�`:;C: BUSif12S5 011d PfOfB5310f1S COdO�. CONNECT TNE ABOVE DESCRIBE�E%ISiING�WEILiNG TO THE PUBUC SEWER. CONSTRUCTION LENDING AGENCY � I here6y offirm that there is a construction lending agency StGNEDTHtS DAVO� w_ for the performance of fhe work for whith this permif is OWNEROR . issued(Sec.3097,Civ.C.). �"���'NT nooaEss Lender's Name Lender's Address I certify thot I have read Ihis applica�ion and sta�e lha�the abova informa�ion is covect.I aqree to comply with a!I Covnty ordinonces and State laws reg�lating Plumbing o�d Sewers, and hereby outhorize represeMqlives of this Cou�ty tv enter ' upon ihe pbOv mentioned io rty fo�inspeciion purposes. RCR EY; �i�� 7/31/86 Signafure of Permittee Date - _ SEE REVERSE FOH EXPLANAT01tT L�NGUAGE � $ w M �� M . �'��� �' ' -�,��, M �..�u � t� u°V�� • '.�� ����p $V[" � ���� . �� �� �8',�M�� �+� '�..����� � � � €c �• 8 =, w� ���g 'nY�'"�� � Q � � 3�:� �+� � � '���;��. � � M��•�.������l � � �M A � . �} • ��v �Y Y W� ��M �� � �`�`�,�f„���¢g��� $, 4� � M � ��+ M Q �q � . � F�� �..�� p CI"�����"'L � R • �'�'+M � �' � . �S �'� � '� w� . ��,� ��.� b,� �„�� 5 � g �'s. .« Ca �. S ����� �o�:':�g g ���"' �— � cj �' p ��'� ����v"�,�� ��Q�¢��m������ �: a�,t a/'� � �+ y���4 y e���M��'q D ���.�,�, �.�,• i � � Y � y����� _:, .��" �� �n`� ���� �w ,. �,� „_,m � .r „ �, � . �8�����`�o � ���� � m �� �����' u � v � Fa �,�,.Z. �����Q�` � ' � �� � �� �����, o ������.�-� � > � G '� Z � - , '.., � � , ti . � �e 4 •' • z � , I � S � � 6 O � N �p{ ����°� N �O � �„�-�'� a ����'� �4����� .--" ���_.-�- � �i��� ° �� �.�s- � � �� � ��� ��� . �_ _ - - ����� . �--�.'' .�_ �--�----