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HomeMy WebLinkAbout1587A WORKERS'COMPENSATION DECLARATION I hereby affirm that I hdve�o certif'icale of aonsent�fo self � � � � � � -� � � � � ins�re,or a certificate of Workers'Compensotion Insuronce,or �°A°szo � a�ce�fed , e f(Sec.3800,LabC.) �F�B�;RE�.e,a" APPLICATION FOR PERMIT � � � -� � ��� Poi cy No: mpany ��• �11T1C'1 �cs , �� . - ,..__, ................. ..... . . . .. , . ...,.,.,... � � ❑Cen fi d�� ebY r����ghed. SEWER�- SEWA�E�DYSP �%�iL` . .__...._. . _._ . �Certifiey�dgcopy is filed with the wumy boilding inspection COUNTY OP L05 ANGELE'S� ��� �� ��BUI'LDIPYG�A�iD:5dF�1'�"�'".."."'."��� Date e�r'ca�$�pplicant T• �''2"E'G'm�71 FOR APPLKANIT TO FILL IN CONNECTION DATA ' �.��CERTIxICAiE�OF EXEMPTI'ON FROhiCN/ORKERS' -� � � g���DWG ' � � /� �. � COMPENSATfON"INSUkf�;RCE "'� � noouess � sranoN oevrr: . .. , ��Th s secfioo need not be mmpleied rf the work nvolved�by the hwNHo:E REpEaEucE uP�R �p'ermit is for one hundred dollars(5100)or less.) �ocnurv � -ioweR � N'cAREST NPE OF CONNECiION - IENGTH FkOM � I certify�thdt in ihe performance of fhe work�for which this Ca0555T. Y, cuxs �.� �ti.�.To"a.i " - � �� 'permit is issued,I shall not employ any person in any manner Pc N0. - "so as fo become subjed to Ihe Workers'Compensafion Lows. � �� ���� �� � � � .. �. . .. . . , . OWNER _ CO.IMP NO. JOB NO. � ' .'. .. � � ADORE55 PO�JJIJ�l . � . .. . .. TRUNK PERMIT NO � ROA�PERMIT NO. Date �Applicant �' � ���� ' ' "" '� -' "' � AFFI�AVIT WAIVER cASEMENT RECORD INSiR.NO. �ATE �Nb710E�TO`iLPPLfCANYi If,�after moking ihis Certificate of -�� arv ret.uo. fk^mption, you��should���bemme su6ject to the Workers' ��A� rpensation provisians of the Labor code;you�must forthwith DESCRIPTION :OTNO. HWY.OR ST.WIDENING � � wmply with such provisions or this permit sholl oe deemed J'y� ��feVolted. B:OCK TRACT ��v�'�✓ g�ATEENCROAC4MENT '' ' " ' ' ..,. ,. . .... ,, , . ....... . , r PERMITNO. � - �CfCENSED CONTRF,GT6RS bECl'ARA710N ' - No.oF ei.ocs. SIZE O"LOT NOW ON LOT � I hereby affirm that�l am licensed under piovisions of Chopler use oF ' �9(commencing with�'Section 7000)�of Division 3 of ihe 6usi- eu�aoiNcs �il1Yi RQ$ CHARGES - . � "`ness'and Professions Code,and my license is in full force and �• �(p�� /y �q /{� "'� 'E�fBCf. , � CONTRACTOR ���LL'1.Hl.V LO1Y S 1♦ CONNECTION CHARGE fEE �, � .� .._ .:_.,.. ?. � � LicenseNumber 4�4S8rILic C��53 r'nl�_ AppRESs $2� �e� � � �� en . [$ n /' REIMBURSEMENT FEE -��" � �0�11OCfOT� �'reema� pp�e p/4o,�p p�}, DISTRICT NO. GROUP MAP PROCESSED BY '��' V . � CITy ,yy 1a'C�, �j�ma, TE'�.NC. . '� .'.'.. .. . . . . , . .. ; ' . . � HK GG O SATE LIC " " � ❑I am exempt onder Set � of�the L.A.Co. u�ENs�No. aass F � � � � � � � � No. DESCRIPTION OF WORK ge v � PlumbingCodednd or5ec. ofthe , F�NAi � .��,te�� VAUD T�01� S . � � � �� � � HOUSE SEWER CONNECTING TO � �ATE , ` � B.8 P.Code for�ihe following reason � �- vuauc sewee / y , SEPTIC TANK,SE'PAGE PIT OR Z ' ' . � ��� � � ?ITS AND/OR ORAINFIELp FINAL � .., DpiB � HOUSE SEWER CONNECING i0 -'" BY � :... '' «. � '.. '.. ...... FRIVATE CISPOSAL SYSTE . . . �.�..- .�. $i9nptUle CCNNECT ADDIiIONAL BIDG.dR- � � � - � OWNER BUILDER bECLARA7ibN ������- � woeK ro HouSE sewee � I here6y pff rm ihai I��am exempt fiom the Contractbr's'License�� �xiNF��Fssv00 GDevwEiRAMnNHote � - Law for the following reason(SZCton 7O31.S,BUiSnBSS�anCl Pf0- ALTER,4EGAIR OR ABANDON HOUSE"' "'�""" ' '�"On5 Cocle�: SEWiR OR DISPOSAl5Y5TEM � r� �/ ` % � c�'.Q ! �� � �_. I,as owner of fhe properly,or my employees with wages as , � , iheir sole compensation,wi II do the work and the strueture � �:.e c d . i �� is noi intended or offered for sale(Section�7044,Business � � and Professions,Code): � QWNER'S Permit 5 !� � p o���J�, ❑ I,as owner of the property,am exdusively con�racting with AUTHOR�ZATION TOTAL FEE ' . licensed coniroclors to consiruct ihe prolect(Section 7�44, '�HAVE AT THIS CA�E A CONiRACT WIiH iHE 4FRE:�NAMED CONiRACTOR TO 'm�`%l �_�'���-' �' BVSIfIC55 Of1CJ Pl0{ESSIOYIS CO(I2� CO�NECT iNE ABOVE DESCRIBED EXISTING DWEL'.ING TO THE,PVBiiC SEWE�2. � �. . ' CONSTRUCT�6N"LE1JDfNG'A�LT1�Y .'. ".. ..._.'......-' �" � �/r� � C'�"���"'S b � I hereby affirm ihal rhee is a consiruction lending agency SIGNEDTH15� DAYOF � 19�1� � far the performance of the work 4or which this permit is owNeR oz ��� � - OWNERSAGEM1i � � issued(Sec.3097,Civ.C.). Lender's Name - ' � � . HD�RE55 . Lender's Address ; . ... : �.' ,�.�� . . ,. �.. ..,� �. , [,;:'. .,::.:.,.. .,..� �_ , .. .. . �. . . . � � . � . . �� I�ce�tify 1ha1 I have�read�this application and�state�ihot ihe � � � �' 66ove information is mrrect.I ogree to comply wifh all Counly �ordinonces and State Ipws regulo?ing Plumbing pnd Sewers, - � ' , bnd hereby authoriie representatives of fhis County to enter � upon the obove-mentioned properry for inspeciion purposes. �14W1��t�.M��['.K.— r�J'"'d-S g`.b Signature of�ermitfee Date SEE kEVERSE FOR EXPCANATORY CANCUdGE - � - " � � __. ,_...: ....._..�.. -- — -- — ;: 4.. ,� :� ,,,: . �s�sr��so�s�r� - c��4.�aci�r =.f . 1._.. .. . ,�a�r�-�ua�.����a� � � APP�O&�AdS oah _,INSYECPoR55IC+NAIURF _._�_`�..A.,�,�.�..,.-.y.�. T17EPQI7S+EI�iIfcLlYl$fSa�nxfi�ip:�m¢heC:or��acfa?a NEW HOUSE SEWER . I.1CCPiSC L8W�YDY @Y1N{6IIOWtliF'C28&�All`SCG�7�31.5, . � � e'3aesiness .znd.7vojessdoa�.s Codeeje ti,ny neg ar roursiy . .: CONNEC7 ADDITIONq:�� - - wbecb reqeess�s�a g'�¢r.nit,�crosasyrracb.adaer.Empvovs, . �':.- BUILDING OR WORK ' ' .. . . �Qmp2Aq$�OP TB,ifd4}'@jyy g�l'&7d�$e"t6t'JEi 3tS Yd'EfPfiNC2� - SEPTIC TANK.SEFP,AR(5) . .. . .. .. . . . .,.... AND/ORORAMFIEID � ......... -�1ddSlilP@P�y3'4tffiR 3ba-a¢pi!�fi,:a� �ac.;b psrmet to fals Li . signed s:a3er.w�ra2 Y6at 6e u l;ter..sed paarswtnae ta tbe - _ cEssro:.i❑ umwei.i❑ . . . . � . � � . .�. . , gyroe�isiasxv��f:be C�r�ctovctarF Lice�¢X.cw�Cixyx3dsr 9 Ib .` AITER,REPAIR.SEWER OR . . ... {COili9Dd¢W2Effs8 L.Y3.�'S4'CIGOW I�•OO�C3)'�TIKSSOR S D�iSJ6 '�� SEYJAGE DISPOSAL SYSTEM �—'— DISCONNECP PiUG AND � . �76M�7QSS Ji�P1'16�P15YEYNR4�wda1�ar thaa h�e as exermprx .: ABANDON HOUSE SEWEk tberaf�nns anrd 86�fiac�r".�t j'or±Xss¢1kge�exerrepEfan.Rxy ' BACKFILI SEPTIC TANKS❑ � ' � LiOd6YY0iE Of SCtYS6A]SEy%.S�,yo cny app8sccr�is:,�os�B,permsE SEeP.PIT(S)❑ eEssaoo:s❑ � - - _,_._ s�udpsece 2'na ap}atdeaeat tfl ra eaviE pe.:aPsy nf saas mw+s tdrr� ('< ". .,. �: :,� - �- _ �e haett�irsd dod8a�s°�SdU�.r ,.. _ _ _. .=w.,��. �,y+ � � . ....� ... .' g9 N&Yp16 OWRi.'[flh�'L"1C C ��.. . . . :�.. �. ..�. .: �. �. . � " ..n-.�.� -.: �r:� . :-••� r„.,,�. . .. . . � Lhe strii�score'se acit sade�aea�or o#E��c.sxtlw�rt�, d � �- . - . .. �. ,...�.. . . .. � . �.�:,._��..�i,.. . � :.. ...,, _. .. ....,,.,. /Sec. 7U44,�us4ssas,c��td Professews�i.oda: 3"--^.ox. , -. ,.. � ,. , _ _. ..... . Eractor`s L'ueaue Larv dbes saos dy Eo.cros�. r � properPy auho brasFds or 4v:spror�.s t��eraaw.��d wbo da8s .,,.._.. � .:.�, -�. , ,�.. .: . .. .. . �... . .. .... .. . .. . ..� .... bisa.aelf�avaFtidad EbzF s�sNc�u dmlbrooensa,nts .':.,. ._ . , . . .. .. . . .. . . .. . �_ .. � _. . . . .... � �. asacb�rk , ,_._....,,... �� � ' . >____� ;i.En:dcd�r n,8'ere2 faa�sal�.Yf&ofeever, #Se mre . ...._ _ . _. , . " .�,_ .hreildiiig or a.�ir,pros�eiiz as sold zi,eaks`z�e:a year mj �'.....- . . . . � . ' ' . . .._.... . ... .- ..`� ". . �..' . . ....._....._ennsple2i�� abe aumaes-Uar'!�r sua�S berre 'll�e br�ader. .., . ..�� ' - . ., .. , . 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