Loading...
HomeMy WebLinkAbout1765A � WORKERS'COMPENSATION DECLARATION Y�� . � �.. � � , � . �. I hercby aKirm thot � have a certifimte of consent to self . . � . . - , , insure,or a certifimte of Workers'Compensotion Insorooce,or �6�+70 , . . . , a�"��'�°°`oPY„".eor es".'e°°,`'b�., "�'�".e,81� APPLICATION FOR PERMIT Policy No: � Compony �s � �� . � � � ❑Cenified copy is hereby furnished. � � . � SEWER - SEWAGE DISPOSAL - . , e.rified copy is filed with Ihe munty building inapection COUMY Of LOS ANGELES BUILDING AND SAfETY ' department. � , oa�� aPPi��a„� FOR APPUCANT TO FILL IN I�t3v• S�CONNECTION DATA � � CERTIFICATE OF EXEMPTION FROM WORKERS' � � �iia� � COMPENSAiION INSURANGE � �ooa¢ss i � sut�aa ��-f. ,�� oevrH . , : , (ihis section need nol be tompleted if the wwk involved by the � MnN�F atfEyEr+CE � � uwFR � permit is for one hundred dollora(5100)or less.) - ��'��� ' . rar,rsrsesT rr�a mr+ractwN �rucrN faavi 1 cer�ify�Fot in the perfo.mance�of�be wak for which�hfs caosssT. aC V Y. CURB. P.4 � M.t.rov.i. � .Y - permil ia issued,1 shall nol employ any person in any manner . n. � P.C.NO. � so as to become subject to�he Workers'Compensolion lawa. pwNER 0-:' b O H� ���N'P��� 10s�'�O. G � - ��� / 6 TQUNK PERMIT NO. � ROAD PERMIT NO. � Dnta � Applicanl - A�u V a `�°o�^ . � , NOTICF TO APMICANT: If, oNer making fhls Certificate of ��n, ��� ./ AFFIDAVIT WAIVER EASEMEM RKORD.MSTR.NO. O�TE o � E�emption, you :hould become subject to the Workers' iFG�i '/ w � Compensation provisions of�he Labor code,you mast for�hwi�h oFs�aivrida torrio. - Nwv,qtst vno[wai� . - d- comply wifh suth provisions or fhis permit shall be deemed ` / feVOkCd. � � . UOCX � " TRRCT � J M STATE Er1CROACNMENT . � LICENSED CONTRACTORS DECIARATION - !'�°_°F e�°�5. I . �+�T r�o' vze or�or Q Q r,ow or�wT ( � � I hereby affirm Ihot I am licensed under provisions of Chopter � �� � , 9(commencing wilh Section 7000)of Division 3 of the Busi- e�ao�taGS /L ~ Y K oukce5 � nms ond Professions Code,and my license is in full force and . eff«t. � ppr.ira�R�q COMNFCTION CMARGf FEE License Number Lic.Class - Ap�u rsewsuaS�Nr� � �'OnhO[iof �p18 CIN ti y ' TEL.NO. L � �95 aSiRICTNO. GIIOUP hWP � PRpCESSEDBY � BK PG n.� - �,�. �. -3 �Gi�-� � ❑1 am exempt ander Sec. �of ihe L.A.Co. iKEr+st r.p. , R,�ss ' - Plumbing Code and/or Sac � of Ibe �� " SCRIPfIONOF WORK RE H�� � � MOUSf SEWER CONNFRING 70 77 UATF G VALI TIbN ' B.8 P.Code for the following reason � ������p �� ' � �D�O� � , SERfIC T�NK.SffVAGE PIT OR HNAI . ' PIiS AND/OR DRAINFIFID � . • Dote - Mous[scwta cor+nacrn+c ro aY � . . . - AtIYAIE DI Y . ' S19t1atUf8 ' CONNECTADD1710NALMDG.OR ►� � � � � OWNER-BUILDER DECLARATION . woxK ro Hovse s�wex - � � I he�eby oNi�m thoi I om exempt from the Gontractor's ticense � e�iNF�cessvoo��.'E000rvrt�iRiar.�uN�i°q�[ � � �! law for Ihe foilowing reoson(Sedon 7031.5,e��5�e:s o�d r.o- u�R,�P.,�R�a���,� -- - � - ��1 7 6 5 A fessions Code�: . s�v+eR oa oiscoiai srSteM . , . ❑I,os owner of ihe prope�fy,or my employees with wages as - �j�'• •-• � � . iheir sole mmpenmtion,will do Ihe work ond ihe structurE . - � - � is not intended or offered for sole($ettion 7044,8osiness- - - _ . � • '�7�J�� � and Professions Code). OWNER�S Pe�mit f ❑I,os owner of the property,am exclusively controcting with � AUTHORIZATION TOTAL FEE � ' ' '2 7��`_' I�CRIISBCI f0l11lOC�OfS�O COIIS�IUCf�F1@ PfO�ECt(SB[�10l1�OA4� I HAVE AT THIS DA7E A CONiRP.�T WITM iME MERlIN NAMEO CONTRACiOR TO � BUSin855 011(I PfOfB5510�5 COfIE�. �� CONNECI fHE ABOVE DE�IBED ERISTINC DWELIING TO THE VUELIC SEWER. . � ' O Q O O"�O 2 � � CONSTRUCTION IENDING AGENCY -� � � ' � I�hareby aHirm ihat Ihere is a conshu[iion �ending agency SIGNEDTHIS � �A �� - �- � -� �� for the performance of Ihe work for which this permit is �R� � � � ISSUBd(SGC.3OV7.CIV.C.J. . OWNERSAGEM^� � . . . _. � ADCRESS�fJ �^Q A �+C, �p�, � ' Lender's Nama � �a�a�,•�nad�a�s . I crtify that I hava read this applkation ond stote tho�ihe � - . � . � � - . - � " above informolion is mrrect.I ogree to comply wi�h ail County � � - � �: � � ordinonces and State lows rogulating Plumbinq ond�5ewers, � -� � � � � � . . � � . . � - and bereby authorize representativas of ihis County to entm � . . . � n f above•mentioned roperry for InspeUion pvrposes. . ' __ � . � � . �6r �3 � ignaiure of Permlt�ee Dai� � � � - SEE REVERSE FOR E%►LANAIORY IANGUAGE . , 1� S� 2��g £ ,��qW° f�M ��^q o�,�c� °c T' . C`�(l �'-° c� �+y 'n 9 M � - ^�F (�Z O'� � 01,��� �!„�. ,� � ` �� i�'�a NT p O ?q N� p o� . . . � 'O. O� uN �. �Y . � �� . ��, �G �� a ,oa �� f . . � 9 N`l <A h � N \ - , , ` . � . � ' . ��ZN �� �A m � . .. 1 . . O A � O �'\� 1 � .y . ' , , .. . . � J 1 q . ,` " m • , . � ��• . - , . � , � . . , . . . � . � . - � . . . . . � . . . • ` • . � w.. � . �, , y rN. � _• __- ' . ? A " , ' , `� � " N : ' - � � . ' " , . . � ' � � " a , �; - � ' . . , �: ' . � � f !' r , , � . ' ,�� ; ,.' ' . + O � �, _� . . . '. J . . NN `�4 � - ' ' �/ ' � , . / , . .� t !� N ,, . , `/ r . • : • , ' 'I i � ' ."', ` _ . ,,,1 ' .,`'( , .;j' `_- 1; ' . �r' , - � ' . ' . ,' ;�. . . / . � , �f� t - . ' � � - � . � � , 1i � . ' , _ . . �� �a.£ a� `" . . . . .. � r. �� 7 �� Q � - � � - � � �'.�'ii o � : � �, y, . + _ . "r_ �. O C m O �;� f+ :r L. �\ , ' � ^ �K o y�'.� �•P-m ;; �a'.v� t..�.� � � �, ",� =t V''�O t'n�sY+.`'^'^� c� O t^ Y'.' 'a F ? t,.;, � `� - . .�t,, u �t G � � „n.T .� N ^ N ^U . .. � . ", o- K q � v� o o. y ;,1 U...... � . x • � o �`"° a;��::�_`'o�".a-�'�.,p Yw`�^��� „�" 'd;,r G W .. o 0 .. . . . . r�.:�, p � .c- �� e' tn —� c.. .-..? ���. , �- � � � p p ��' O� C"i-C-ti N P.O n C"'`C F.ta � y'ct m fo � . ' � s��y � :. �ir� ' m o a.:'� ...�.o ^ .. � p �' °�,p`"' l'� , , - . • � �,c D �,;ic O �-. .ia --��:t � '^ 7 "' ^-:� c.�. v�o c:`v,L -' 7 p c Cr�1 .' . . , _ O G' C' �� .. « P..� �c1 O S'` N�.�. �.i L, `^ e. ^' Fi u '� Tn 'S� r. �I� .. F"� .� 4 '^` � N v�� �P • f� Q y n Y y� , .. , � t� � f? "�w w u.'�.. p N p �",o �'o'^ � o ��." ^ ��� M '" —o o.w o c a n � op�'v�r.C'1-..i'' o F ° �� r n .. � .. . : . . . ~ 0 � � A � �.p K '� G. t3 ,Q p� Q,w p p�^ «-+ � �,.. y ... r .1 G °'� �^o =' °t''°a o`' :..`r �, �.o t-` . =, �o ° '�! : r� c:.T �� Q,�cr.� `0 a,� n c � ��. � � ? '� v �� a- y � .r...� �, k 7 \ N � o � ia.i+.c��� � �Q � -�+?.� a.��' ;� m.� y �\ '. . ' » ��'.-.,., U N °.e. �,,,oo e� ,�� s�,�.w � , 4 ' � � � � • . . , C� (D ��.�=+v te. tT'� � "' i � ii A V�� N � � : O�3 y O . , . . . .. . N (� ' � P'F� �'� N G�" 3..0 �.�.L''� x ::'F ti �y.", � ' � � . . . " � " � �'�� ci K �°`L,.� O � 7.»�: t° �^C,�� n'= i� O n �. - .` � , . _ . . . . � � �' . , p • �� O.0 O � O 0.�',�, L„e O �� O w� .� ' � �� � . . , . . . � .P�'' ...p �, e�a (?'� �_.�'O��.W P�, O.+.P O�.X.��. . � . . - . � . 3 C � C 3 �.3 �✓'.�, O P '? Y.��-w N �N',�Q v ' �n _ , . ,� � a,� �, a� o ,� . � ., . , o x � a�E° �- :,. a�. �-,�A Q ` , �aA � � � A K_ _� �� � . " ' . .. " p � l2 l� � � n n.�• d ' � ��L K �Y � 7 � � O � ~ . . ' . - � � - ' . . . . � `�'S �y � .'T A�O^� . �' T� �• - » � �� `• � "� . �. � 1 . . � . . � � , ' � 3 � l . , , . . , , _ � .. � �-� . . . �� .. - . . " . � a. , ,,