Loading...
HomeMy WebLinkAbout1479A . . WORKERS'�COMPENSATION`DECCARAYION �� �� ��� ' � � � � - � � '-� � ' ��� '� � ' " � � � I hereby affirm thot I hove�o�rertifimte of consent to self , � ., insu e,or a certificote of Workers'Compensation Insurance,or� �b^6°z� 'a ce�tified copy�hereof(Sea�3800;Lob C.J ce aee(a6v.a.�at) - � --�-� ��-��� -���- --�� �� ���- � Pol cy ompony st, Funa �, � APPLIGATIO�N�FOR-PER117'll'1` c p _.... ❑ce.f�� ��i�eby furnished. �YEWER - SEWAGE DISPCySAC� '>�Ce rifie�d}gmpy is ftled wi�h Ihe county building inspect�on � COUNTY OF LOS ANGElES . _BUILDING ANb:SAFETY � �-""- �- `��``��- �� -� . ''�Dote eP�rl���s�pplicon9 �'Teeman �pR APPLICANT TO FILL IIV CONNECTION DATA -� � � �-'CERTIFIC,4TE�OF EX�A1P'('I6N FRCfM�ORK�RS' �- � �� sui�oirv� ' ' " ' " COfvIPEt�fSATIdN IN5�RAAfCE ` ���� �� � � � nooaess L � ��y sTn*ioh oeFTH � � (TFtiS SeCfiOn need nOf�be Colnp�etec�i�tfte Wofk involved by the � � i�A,iT� MANHOLE REFERENCE � - UPPER '��� permir�s for one hundred dollars($t00)or less.) �owez NEAREST .� , f � TYPE OF CONNECrION ' �,yGTN FROM ` I�certify�thot in�the��performance�of�the'work��o�r which �his crtosssi. �. t�RB p.�. N,., TpP.i. ' permi�is issued I shall not employ ony person in any monner P.c Nc } � � '" so�as�o become subject�o the Workars'Compensation Laws. owNea ANDEN GRP CO.IMP.NO. JOB NO. �(� �'�� TRUNK PERMIT NO. ROA�PERMIT NO Date APplicant .. � .. �� ... aDDRE55 P�"BO,X � 2 � p�p/�y�����A� AFFIOAVIT 'NAIVER EASEMENi RECORD.INSTR.NO. �ATE � NOiICE'TO APPCICANT: If, after making this Certffico�e�of���� �iTv Covina re�No. v � 7 � .. :.Es�mpiion, you�should bemme subject lo the Workers' �E�a� T�� �"�pensation provisions of�he labor code,you must forihwith oes[xittioN �Ottio. Hwr.oasr wioen�.r� ,aply wi�h such provisions or�his permit shall be deemed ""�EVOItECI. BLOCK :R.4CT STATE EN[ROACHMENT ' �..� �����`� LIG�NS'ED�CONT12ACTORS DECIARATION���" '� � ryo.oFamcs.. � . � PERM!T N0. � -. , ' .... .-..... ... �.. _ SIZEOFIOT NOWON`LOY..`•.�. . �I here6y offirm ihat j amlicensed u de provisions of Chapter µ�E OF , 9(commencing with Secfion 7000)�of Division 3�of the Busi- suimiN�s J�1� R.G$• CH.aRGes �.ne'ss'ond Professions Code,and-my license is in full force and � .effec�. �pNTRACTOR V CONNECTION CHARGE FEE } License Number 47488? �;�.c,oss� C34 ApDRE55 REIMBURSEMENT FEE o �� .lTGEII+�ATSDqte �I��I�O � ry�R /�.jpo_eAr� 'JISTRICTNO. GROUP MAP PROCFSSEDBY v ' �OflifqCiOf ��rY . . . . _ . . . H OTCIF�. TEL.NO. yW��� �f<}G eK vc Z � C I am ezempt�nder Sec. of ihe L.A.Co. � icE�r�Se No y�1�t887 aa55 ,�.,l�t �� � o � NO. DESCRIPTION OF WORK FEE PlombingCodeand/o Sec. � � ��ofihe � FiNq� � Ho�se sewea coNn;ecTiNc ro 1'7 dd onre ���� ,r,r,.� VALIDATION B.&P.Code�for ihe tollowing�reason�� � � PUBUC SE1vER y. � , ' . '' . ' . . , SEPr,C iANK,SEE�AGE FIT OR FINAI � Z ' PIiS AND/OR DRAINFIE�_p . � ' Dp1E HOVSESEWERCONNECTING?O Br � - �.' - -::�+. ...: �., PRIVATEDISPOSA�SVSIEM � Si npiure �� � - -� 9 CONNECI ADDITIONAI Bl��'i.OR, ► � ' � OWNER BUILDER DECLARATP6N '� � WORK'O r+0u5E SEWER - OVERFLOW SEEP0.GE PIT,DRAINFIELD ' �I hereby�affirm�that I am ezempt from the�Com actor s�iC2115C E%TN..CESSPOOL,DRYWELL,MANHOCE� I� � Law for ihe follawing reason(Secton 7031.5,Buisness and Pro- n�he REPAIR Ck ABANOON HOl15E L I �� �•C�1 '`p`�.ions COCJe): ' ' � SEWER OR O�SPOSAL SYSTEM ' ' � I,as owner of the property,or mp employees with wages as 'T�^ "+i f,�'�'''! � �� Iheir sole compensation,wiil do the work pnd ihe s±ructure � is�not intended or offered for saie($ection 7044,Business . - :� . ,,. .,u.�� . and Professians Code): OWNER�S PCrmit 5 ` � ! , ❑I,as owner of the property,am exclusively contraUing with AUTHORI��ATI�N TOTAL FEE 27 rjQ �G�y�`u 6 �licensed cantractors to construct the proieot(Sec!ion 7044; i„ave nr THis oare n conrawct wirra rNe NeReir�Nwneo con:rancroR:e � Bu5ine55 anC�PlofC55iOn5 CoC�C�. COIVNECT'ME ABOVE DESCRIBED E%ISTING DWEILING TO THE PUB.IC SEWER. ' CONSTRUCTIbN L�NDING AGENCY � -���"� "��� �� r— p� �j�! ��' """ ��""���� �" SIGNEDTHIS DAY� d t9,�y I hereby�aifvm thar�ihere �s a��construction lending agenty OVfNERCk ► � for ihe performonce�of rhe work for which ihis permit s ov✓HeesnceN• 'Z„A:�Cati� � ..'issued(Sec:3097 C v..0) .. ... ����,�'����`•���,�� ' � � - � � , ' .. � ADDRE55 lender's Name � -� �. '^�" ' . :.� - -.. _ '.....,:.`- ,...:�-.'.. ,,.. .�k.".- ..,._.:t... y . ....".::'.u. .._.;m6 ��..,...:'... _ ..r:_:... 1..� _..... _.. ._. '. .,. ._.......... .. .... . ... . .... .. ... ........ . .. . .. .��Lender's Address .. . ... . .. ._,. _ . � .. .. ,._.... .�.. ........ .. . . .. ,. .. . , � . . I certify ihat I have reod�this application and siate th6t ihe � � - � - � above information is mrrec�.I agree ro comply wi�h oll Coumy � � � �- � � ' � � - -� ,. ordinances and Siate laws regulating Plumbing and Sewers, � and hereby authorire iepresentatives of this Counry to enter ' ' � � - � � � upon�ihe above-mentioned property for inspection porposes. . .. .. ., ........,... .. . . . , .. . . ��( � � .p,�.. .. . . .. ,. .., . . ' '�Cr.w'`c�37u„'.+Nt i?Fa-- �'°'�'�'�ry . . . . .. . ... .. . . Signature of Permittee Date �����- ����� �� � �SEE REVERSE FOF'EYNC'ANA70RY'LANGUACE" -� ��' � � �� �� � '' � ' " ' '� _ . _ , .,-,..m��.n����..� . .: ,.:. . . . .. ;.a,. fP7SPELTOR'&M6TES � . . �... ,� , . ;;Tf a ; ,... .;: ,, ; ` � ; �,._� �V9PSLIR-E#UIL�lE?d D�+�Y.AI2Ft.TiOl� - , �_;;:._ _ , . .��---�,.��: �P�Ro,jAL�J DAFE INSPECTOR'S SIGNATURE �� .. .I]iM8�7p a1{�iPtll Y'�k'at Y fl9Yi @3@0pY iP�LI t`Il@�OnYCBttOS'S u w nouse s�we� .,:� � Licemse Lacv£or t�e£allowlug'reassn/Sect£are 7031.;, � $ussxess und ProFes�smru R:ode%:Asag cst;,i• or cosan8y CONNECTA�DITIONA4 i+ � � v�hirb�rayvsres a pzrnxit ta corugncct, alter,4waprove,� �,�' BUILDING OR WORK _, , (jgmpJ%gVj or re/raer aray strnsau.e;�5e4br an sRe ixsssnee> �' SEPiICTANK,SEEP,AITjS) . . �. .�,. ..�.... .. .•_ .. . . . AND/OR DR4IM1FIELD - 6LS6 T2t�Pti/'6S t�Jt:��68L693$�OT StlCfl g."12i�DOr 30�C R ��� c�.ssvoo�❑ oavweu i'j i � . . , ,..... . .sgned�awtemessa abat�e i�lieensed pursuan>Er� ehe A:TER,REPAIR.SEWER OR � . . .. . . . , . .. .. • r�Ni91789{LT95�8fJii-IJ S£LCP6LP�P°'S��¢9dSC L�P.PY rCXiGf58¢A°9 SEWAGE DISFOSAL SYSTEM ' ' 8 J��������� . . $ussness amd ProJaisiom:CadeJ ar tbea�e xa e.�ravnpt xa DISCONNECT PLUG ANO tber_`romn aaar`t&a basas yar ihe rrlte d e.xem tsaw.An �~� ABANDON HOlISE SEWFA � — � `� � p � BAIXFIllSEPTIC TANKS� . . ' .. .... .DYOI6Y�#oJSec'cso�7031.5 by asy'appdicm,aJo�apemaia .-��; SEEP.PIT 5❑ cessroo�s O .�_ �- � � srebjects zhe � Itsarns�a ra ssv43pe�aalby nj��mt snorz abast ,.:... . ,: , :-- .. . . ._.. ,,�„ jrve��a�ad r��ts5a�,r.: �. :_ �-.. . .... ',* _.. _ wuer the r p�e ` x� and _ ❑&as the u � a ry�'7a dc e woxYs, . ,:: . . _ .__._. r,._ � ;: �.�,, '. � �_��, , ,the stivctui+�xs noc`iriteaded or oiFerad:or ax1e. ,„ , .. .. ; _ . :.. . _ �._ „ .. � .� Sec. 7044. easssre.ss and ro easions e: ._ .ota- . ... . . . :. .. ..; . . :,. . , _ _. . . .. . . � .. . .... . . '1� . ..... .. . .' :, "t'reu ...s L3.r.snse Law does sen8 appYy to aan o �o� �:.. prvipert�v wbo BreiJds or em,¢wwss therea�:and wbu doe.s _ . _ . ,... .,. . . .. _ � � '-�' - � z) � ...=:" : .:�_ ;.. . . .; �.. : .� __. __ ._ .__ .., ,. ._ .... . ,.. . � . . suelr work bi,msel'j proyided tba3 asrcb smprovevnsnPs� . . .. . . . . . _ _. .. . . . ._-- .. �' ...� � . �'. . ara'�itnt iner.x�ded ar ojjered�ar sa1e..�j,houseoer,eb� ,, , " ' .' building os 5mpmvexseni u soTd wwIItiben�!�e,year of ,... .. ......_. . ... .. _... _ ._ . ..,. . _ ._.. , . � r. ;.K��- �, .� . � . . ... . .... . .'.� ''.�.. �- ' cur.pletfon, tbe ouraer-bui�er wilt baae zbe burden ,, . .-... � .. ... . . ._. .. � . , . ...._..._.._.a.f Prooing'bss be dani raot budld or dm,�+rove jor 3be ; ��; . � -� ...�.� �. �.., . .. .. , ...... _ . ._ .. _ . . __ .... _ _ . . - ` pwDase o¢.,ate,d s. __. ._ _ ._ _ _ '' .'_ . . ` _ •, . . :..-^', • - � ,_ � ., ,a�����E�a�_��_ . ._ . _ , : . r ..� � � . , ,�;_... ���.�.���n�� . . _... .__ �_ . . __ _ �a�� . ,,: , _ ., - c�� _ ,. _ , , ,. . :,,_ .� _, _. � 9NSPEiTOR'S NOT�S � . ' . . . . . . � .. .. . � . - '—- ; ._ . � -- . , . . . . . ,. .. . _ .-. ...........:. .....__.,.....�. �..._................._..._.,_._........:.....,__� ......-.,..,.r.,.._rK..,,.,..,.m�,.,.�.��,me«��.._.�,.:--�..�. ... . ._._._..,. .. .. .,_. .... ..w .:..,s-,r,.«__. . ._.-.,._,- ... ._..,_.. _. _..... ...__..__ .....,.,..,..,...�..,r- ..�_. ,,. . . - � . -. - _ .. .. , ..,..�....,� ...._,.. ...... r � � � _ _ � . � . . . �� ._. .�.. ,.. ..,,.. ,.,..... . ,t...,,.,... . ,..W..;,.w ,�� 4 .n . ._ , . . , . , . , _ . , . . .^,�-+e.• ..,. ' �. . ;.... . . . . . . ,. .. . , . ' . . ... .. .. ,,.,...w—....:'».... -�..,�.:..;...�....... .................. w..._..,.---'^-,...,,. ...,........,..-a,,...-,y..«,.n..�.�..;;e.Mw.+a+,��+.w. . . . . .. „.. , , . . ��...._.........M..M...�..M._. ,. , �rn �... , . . �... _,.... .. �, .. . � .. ... _ ,_. . .. �.� �.' ..', .._ ..�. ...... ..._.. ;. �. . . ��.. . . . � .M . . ,- . . ,., .; ,,..._. �. . � - .-. , ..., .. . . . .� � �,..... „.�...:.:. -.,. , . . -v ., . . . .:+ , . ,_ ...- . .._ ._..._.z... ....K. ._ ...... ,.......... ... ...„ ,.... ... .,.,......, . , ._.�.. .. . . . , . . . .. .,.... ...,,...., . ,.>��ie,+e,r ..., :�.�,x ,5,...,[:....m.:... ..... . .. . .,..,� •' -:;� . ,.� .:. . .. ..... . . .�., .� : .. . . . ... _. . .,.__..... ........ ..... ., .�..-.,�..,�....__�.�...�-�.�...,.�..-.,..w.�,—...,.,+,w..,.�.��.e:,wape,a..ww� � Jw+Y,xv� . . a.'9"."P'wY'„"'M�+M�+m.. ..a+w�..-.?hIMMk'eRMrw*�t^. .in!lY�M...w,r.. , . ....a,.._.e__,.e.+.r-M+--a+� �.�,.,.�:.+er-v. �,...,.�...:�w+..�.»,,,....N,..-xr,.e+..:.:..�».�.w..o.,�:+»....:...->..........