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HomeMy WebLinkAbout0723A _ _ _ _ � WORKERS'COMPENSATION DECLARATION , � � � I hereby,affirm that I hove a certifiwie of consent ro self � �I insore,or a certificate of Workers'Compensation Inwiance,or ��nRezo . '., � , � U a certified copy thereof�Sec.3800, .) � �� `-i°°°ikEv.vbii qppLICATION, FOR� PERMIT Poliry No.� y � ❑Certified copy is hereby furnished. SEWER - SEWAGE D15POSAL � �' ertified copy is filed wirh the counry 6uilding inspection COUNTY OF LOS ANGELES BUILDING AND'SAFETY dep tme t Date�E?��U.�APPlica�' i- fOR APPLICANT TO FILL IN CONNECTION DATA :ERT�FICATE OF EXEMPTION FROM WORKERS' suaoiNc COMPENSATION INSURANCE � nooeess STATION oevrM (This section naed not be completed i4 the work invOIv2CJ C � MANHOLE REFERENCE UPPER �permit is for one hundred do�lars($100)or less.) � LOCFi11TY iowee I certif that in ihe erformance.of tfie work�for wh(ch this �ARE57 TYPE OF GONNECTION IENGTH FROM Y P �Ro555T_ Grand Ave. & Summit Rid e Y. CURB P.�. M�*oP�_ permit is issued,I sholl not employ any,person in any manner � v.c.No. so os to become subject to the Workers'�Compensation laws. owNea gramal ea L i mi ted n �IMP.NO. JOB NO. -Dafe Applicanf ooRE553151 Airway Ave, Su�te t`I TRUNKPfRMITNO, ROADPERMITNO, NOTICE TO APPUCANT: If,.after makllj tflls Celtlflmie of AiFiOAVR WANER EASEMENT RECORO.INSTR.NO. DATE 9 CITV TEL NO. _ ' 'qiption, you should become subjecr to ihe Workers' LEGAL• ripensatio,n prov�sions of rhe Labor code,you m�st forfhwirh oesccivrioN iorrvo 29 MWY.ORST_WIpENING comply with��such provisions o�this permit shall be deemed 42556 �EVoI(B(I. � � BLOCK iRACi STAfE ENCROACHMENi LICENSED CONTRACTORS DECIARATION � - nio of eiocs PERMIt NO 1 hereby affirm ihot I am licensed under provisions of Chapter s¢eOFiOr Now ON iOT 9 commencin ith Section 7000 of Division 3 ot�he Bus�- use oF ( s w � BUILDINGS Single Family Residence CHARGES nass and Profossions Code,and my license is in full force and CFFE[f. CONiRACTOR QY'ama�ea Ca��f. I(�C. CONNECiION CHARGE FEE License Numbe�Qn��� LiC.C�a55 Q � pDDRE55 3151 Ai rway Ave.� Su i te N REIMBURSEMENT FEE � } COnffaCt�Firamalea Cd�lfOme 6/6/85 � c�Tr 1E1.N0. DISLRICTNO. GROUP MAF FROCESSEDBY O ❑1 am exempt under Sec. of ihe L.A.Co. u[eNse No. eK v� V srnre 409610 ciAss B �{� �� � NO. DESCRIPTION OF WORK FEE PlumbingGodeqnd/orSec. ofthe fiNAi VALIDATION � HOB 5�E�R CONNECTING TO � P'y/�� DATE t.Sla 8.&P.Code for,tha following reason $EPTI�TANK,SEEPAGE PIT pR � ' GITS AND/OR DRAINFIELD PoNA� Dq�B HOUSE SEWER CONNECiING TO eY n PRIVATE OISP�SAL SYSTEM .� Signa�ure� '-'d� CONNECT ADDITIONAL BLDG.OR , � OWNER-6UILDERDECLARATION 'NORKTOHOUSESEWER , : I here6y affirm ihat I am exempt from the Cont se �xiNF��esS�cooiGoxrw�RAMnNHo�e � Law for ihe following reason(S2CIDft�O3I.S,BUi5f1e55 O�CJ Pf0- ALiER,REPAIR pR ABANDON MOUSE Of15 COGEJ: - SEWER OR DISPOSAL SYS7EM �. u� �a owner ui ine properiy, iiy e�npioyeea ii� woyes as � their sole compensolion,willydo the work and the strucfure , �C 7 L.3 A " is not intended or offered for wle(Section 70G4,Business and Professions Code). OWNER'S Permit S �Q �j e n � �. } Q ❑i,as owner of the property,am exclusively contrac�ing with AUTHORIZATIdN TOTAL FEE � Q � � v 2 7�O _ licensed contraaors to construcr ihe project(Section 7�44, 1 HAVE AT iH15 OAiE A CONTRACi WIiH THE HEREIN NAME�CONTRACiOR TO � BUSin955 pnCl PrOfe551on5 CodeJ. CONNECT iHE A80VE DESCRIBED EXISTING DWELLMG TO THE PUBLIC SEWER � � ���,`)n U CONSTRUCTION LENDING AGENCY � • I hereb affirm that fhere is a consfrucfion lendin a enc SIGNEDTH DAVOF ��� 1 [ ,1 f�G Y 9 9 Y OWNEF O ► O V'� 4 i'"`J for the performanca of the work for which ihis permi� is owNeas nc[Mt`� � iswed(Sec.3097,Civ.C.). Toronto Dominion Bank A°°RESS lender's Name � lendar'sAddressSan fransisco , 1 certify that I have read this application ond siate that the � above informafion is correct.I agree to comply with all Counly ' 'ordinances and State laws regulating Plumbing and Sewers, and hereby authorize represeMative5 of Ihis County to enter � upon the above-mentioned prope�ty for inspection purposes. . �-sa�.d�. LO �� � � 45ignoture of Permitfee Dafe � SEE REVERSE FOR EIIPtANATORY IANGUAGE � -�._:-:�� �- . _ ... .. . �� yojM�,,N ���j� i }g g c�slr��.. � ���L = { i � . . , y r,�vn'S_ n� o_ ! • � , � . ' � ' �o.�y� '�'. g �_''zn� O I �� � �Z L� �.m �;G��{ C ��i � ' . � -' r LT r'� � �Rt v T l'42 N � .. i . � �,"� s-^.�9; �i� zn4�"�,� `^ `��� F t � �I i .{ j .` ! , �,:l;��o�.o- �' ' _ 'c= � �,�� i j . 1 � _�., . .. , ` � � ' .. . : ,,. ' cmC�D�� -� �T� " � � � 1 ,i . � � . 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