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HomeMy WebLinkAbout1480A WORKERS'COMPENSATION pECLARATION �.___ .._ . ......... .... .. ... ......_.. ......_...... .... .......... .. .. _. .,. .._ .. . .,-... . . .. ..... ..,. . . � � I hereby affirm that I have,.a cert f cate,04,conseM Jo self , . . , _ „ _, , .....-........,+�.....».. 76d64Rb. . .. ... . . .. . .. sure,or a certificate of Workers'_Compensarion Insuronce,or �� ��� - �� ���,,�ed o{ rhereof(Sec.3800SL�6 C.L d @Saoa,QE�B a�� APPLICATION FOR PERMIT .� Pol<y fJo���?=���Company • r�Ll.l�. . . . .. . � . . / � SEWER - SEWAGE.DISPOSAL �� �Cert�fi�tb ' �by furnished. � � � ' � �� �� �.Certifled copy rs filed wirh the county building inspection COUNTY OF LOS,ANGELES BUILDING AND SAFETY a �,,,,,,.} ��� department. � .. . . . . - . �.... . :.., . . .._ ........ .. �. _. .,... � ., ..._.,.....-..._ � �� Dafe �H O �pplicant FZ'eeRt3Y1 , FOR APPLICAlJT TO FILL IN GONNECTION DATA �� CE�RTIFICATE O�EXEMPTION FROA+1 W�'JkKERS'_ � _�- _ _ , euuo�N� - srnrioN . �PTH � �� ` �` .' COM�ENSATIOON INS'URAtJ"CE, . . . aooeess � � . .�,..,.. .,.... �:�' �'. ....� . ,.:..� . . . .. .. . . . ..... .. ,.,..,.. . . .. . ..UPPER � Th s section need noj be com�leterJ if Ihe work mvolved 6 the �� � � n/wnHote¢EFEaeNCe " permit is for one hundred dollprs 5100)or less. Y ����'TY LOWER '.,y ..I � .. . .... .. '.. .. :.... . TYPEOFCONNECTION �..�.µ � � 1 certify�ihat�n'ihe performance of�he work,for which)his, `�aesr e"� ,� ��'� ��������� -�eNGiHFlionR""""�"'."""„`."` .. , .,. CRO55 Si. .� Y. .CURB v.l. M L.TO P.l. � "'�.. 'permit is issued,I shail not employ any person in any manner � � � �'v.c'ho.�""' � �^-"��" ' '�""" -'' so 6s_to become svblect to the Workers'Compensation Laws. owNER AN `� O.IMP.NO. JOB N0. � .. .d�-'S)v ,.� . ...: �: . ... , ,. . T� '.p./.�...y. _ .. .. .... ..... ... ....,........,.., . _.___.,_....... , ..-...,.... ., '�� '" �"� � � AD�RE55 r O '1]1JA Z TRUNK CERMIT NO. ROAD PERMIT NO. . DOfB � A(J�JIICOlIf - � -- - AFFIDAVIT WFNER EASEMENT RECORD,INSTR NO. DATE N'OTICE TO APPOCANT If, after making this Certifimte of c'�rr ,riOtTj-11cL TE�.No V�818%96'7-9541 -,�,mpflon; you"'should become subject tb ihe Workers' iEGA_ �� �� � ���� ' �� � """""���'�•��� � . , - �P"'�pensation provisions of ihe Labor code,you must forthwith oesckivrion �orHo. � � � � � _„ � HWY.ORST.WIDENING �' .nply with such provisions or this permit shall.be deemed �� "-� �"���" �"-"` ' . �.��revoked- eiocK TRACT STATE ENCkOACNMENT . � .�... �...� .�•.,.........,�..^•�. `�: "��-� LICENSED CON7RACTORS�SECLARAT�ON " . . � - vo.o=s���s . . . . � .,, .._.. . ... ._ ....,�..� PERMIT NO. � .. � � ..... .«., ...,. �-...,., ,..�... . .�.....,.. SIZE.OFLOT , NOWONlOT .. ' � I here�y aff rm tfiat I am licensed uncler provisions of�Chapfer usEOr � - � -� '-�".^-.:..-'... . '—^.. �. 9(commenc ng with Seclion 7000)of Division 3 of the Busi-_.. eu!miNcs ' �� �� �� � � " CNA`RGES � ��� ness ifrtd Professions Code,and my license is in full force and . � ' -"`� �� '""�""'�� ' """"�-���"" � . �'. effeC�. � � COYTR4CTOR FREEMAN COI�ST� CONNECTIpN CHQRGE FEE .._ Lcense.Nu aa� �47488���� Cless Ci�q- noozess 8�e2 �@@C�1WOOd. ..� .... � ........ .. .. _...... ............._.. � " � �Of1ffOC10Y Freema�.�� �oo,e 8I20/86 �,,.�'�a yO�a ' TEL NO e l (�0 4 2 �STR ROU BK MAP �PG� PkOCE55E�8Y Z REIM6liR5EMENT FEE U ICT NC P . �.. . -.:.-., .,:'. :' ,...'. _' ,'" . '.;` STA•p _ ,1 q1 , ' 'UC» ..x._.. ..� ...,,.,. � ^ — �-� ❑ 1 am exempt underSec. _ of the L A Co . , ucENse Nc. y-1�h887 �J4 0 anss u Plumbing Code and�or$ec �� '�of 16e �- No OESCRIPTION OP WORK '�"FEE '� �'"" �����"�� � FiNA - � ��- ' , HouseseweacorvyEaiN�To QO onTe� �u �J�Zy VALIDATION y � '.. :' �. . � PU6LIC SEWER � B.&P.Code for the folbwing reason �.—... . -. � _ � , , ,, .. � . SEPTIC TANK SEEPAGE PIT OR FINAL �� ' PITS AND/OR�RAINFIEI� � Date�� � HOUSE SEWER CONNECTING TO "� -'' "'""""' BY �L���-��.,�,/ .'.'. . '. ., ..,... ..r.._ ,. .,.., ... . .:: .' ..:.:..: PRIVATE�ISPOSAL SVS?EM � '.Si(3nO�Ue �. . .'. ::: � . . .... NNNECTADDITIONALBLOG�OR .. " ,. .... � ' � `� OVJNER BUILDER,bECLARATION � � '� woaK*o House sewee� OVERFLOW SEEPAGE PIT,DRAINFIELD " � �"�" � I hereby affvm ihat I�am ez'empt from ihe Cont octo s.,License � �'M����� exTN„cessroa,oerweu,nnnNHo�e � � i aw for the following reason(Secton�O31.S,BUi51te55 OnCJ Pf0-, ALTER.REPAIR OR ABANOON HOUSE � " '"` s (��?��. " "��iiOf1S COdC�: . SEWEROR OISPOSAL SYSTEM `f � ; ..,'.� ...,..,. .�.... .......... ..... ....... ......... :..... ...... ....�. ...:,:� .. � , I,as owner of ihe property,or my employees with wages as ,,,,,, ,,,,,,,,,, ��'D 4 ' � � C � � iheir sole compensation,will do ihe work and�he siructure _ C ' � .is not intended.or offere,d for,sple,(Section 7oga,ausiness�� permit ' S �� J� � �� 7�r� � �and Professions Code). � �� � " OW�VER'$ , _ _ _r , � ❑ I,as owner of the properry,am exdusively mn�racting with AVTH�RIZATIQN TOTAL FEf '2 Q ' `' ` = �%�s� licensed ConirOCtOrs to,COn5lrVcf the FlfojeCf($E,C1iOn,7044, I HAVE Ai HIS�ATE/+CONTRACT WTH TNE"HEREIN NAMEO COM1iRACTOR TO p COI�STRUCTION ode) �ONhECT iHE ABOVE']ESCRIBED E%ISTMGOWELIiNG'C THE Pl1BLIC SEW�R_, _�� � �f:�,�7''li C 6usiness and Pro�essions C � �.ENDING AGE,NCI'� � ' � �� I hereby�aff rm }hat�fhe e s a�conslruction lending agency� SIGNE�THIS � DAY F � 1� for the erformance of ihe wo k fo hich th s erm t is OWNER OR ,V, �� P � - p OWNERS AG�NI� _ � " issued(Sec.3097,Civ.C.). ADDRE55 ' Lender's Name� . � . .. �:.: , � .. . . . .. . . :. ..�. , „. .. ..�.,._ �.,g�'� `"e�„� z:�e�r _,'+ . , .., ... . ..... .. �; � .. , .. .. .`�,: ._ �-�.�� *-;',. '.. , ...:�-r ^.:�.. . , . . . . . . . � . �+ .:.:..� ...,. �'�� Lender's Address �. . � �. .. .. . .�.�� . .. . '. .. -. . . � I certify ihat I have read ihis application and state that the,..'�. ....:�.... ,... . .,....��. . .���..' .. � ...... ,.". . . ... . .... . . . ... .: . . . .. .. , .. . ' .. . ..,... _.... ..... . . . . . "�above informajion is correct.I ogree to comply with all Co�nty . ordinanres ond�$tate laws,regulating Pl�mbing and Sewers, � �� 'and Fere6y�aufhorize representalives oF ihis Counly to enter ' �� upon Ihe dbove-mentioned property for inspection purposes. ..,. .,. .... . . . ;...:.. ......... ........ . ....,, . . . . _. ,,,/� .. , . .. . ... . �� . �c:, q.� . p�/' .... .,.. ._:� . ... . ... . . . . � . , . . . . ��t J4/\ �A 13iu'�P�.�,�... d-'G'�i�OJ" . . . . ... ' Sig�Permifee Date � ���� ���� � SEE�REVER$EFOREXPLANATORVIANGUAGE .. .,.... .. . ... . .. , ..�.. � . � .' . . . . , . -. :. .. . ... . . . .� . . .� : . .. .....': .. .� . . . . . . . , .. .. ..� ..�:.. , . . ':,. .;. . . , �:. .� , . . ... ,...� �� +,%,.:'�.�.� >..: ...... ..: .. ... < , �, � -� �,. ��aecro�rsr�s M _. �W[��-�Z7iiC�����Ck,��.'�'d(a.�i z..:.__._�.__ _._. __._ . /R�P��VAlL$ oarE �iNsaxroR3 si�Naruae � � ,y„ . T hece'rry aifirm zna�I;�ca�:r�pt froe-�tne Crmtauccar's .. nEw!�u��r . � �, . . Lacense l�w S�r zhe ir,lfia�sag:casor,f�ertimma 7113d.>", � . _. -�s��.-- _ ..,.... Bxskvoess a:ad:f�r¢yesssnsz: 2:'�rJsj.'9ny cvty cr m�avy � � eowtiea aooreiowu . . . , . . :ahic�rcqroiv-er r:,pe�-mA�t�rora�8racf,rsPa,�s;ssu.prov�, y' BUttDING OR K'ORK �fyp=�g(pgJyr ay"yg'fygy yn Yg64^'�FT1 ti'S w$Y6TiCd� ,�'' SEPTIC TANK.SEEP.PIT(5) � � y'��'�'��0� ' ANO/OR DRP.INFIEID _ �J.Pt3'1¢Q:LSI'E.r'�I?¢�rf6Yo�$�O9'S�d'�.e����$2Q�p 6 � ' cesscoa❑ omweu� I . , . . . - sag,rnrwa"stataaseaase 3:ws i.re is#cea�ae��ur�usns an &�ie � ���.. � � . Provss�anc af?&e�aastrvc:te�rt•.:asenss.-r..z:i.�,CKapier 9 ' ALTER,REPAIR.SEWER OR u�m ' . . rCOIitSSe9)6's3a'�'2L'i8.{i,S8CEf09b y(7Pi0)uf 73dr�zsiava.3�}zbe - SEWAGEDISPOSAI-SYSTEM �� �� �� ��' qSCON�PWGAN� Basisress an��rof�esaior,r Codej'ar•�.af Ge:�exemps ABAN�ON HOUSE SEWER _ -- . ..... fFJBfeff'G9i3�d1Yt.�EFDS�f4FSSPY 2PiG t�I.�L'$�tL E9,'�Nd�5E00A,fIlF'y BP.CKFILL 5EpTlC TANKS❑ - FlltllSdr095 n�SEC$8042 y��i�.l uy A'Rj�R�l`$SL�Y'in,j�d4'G fD03TKi5 � seev,rir s�i7 cessveo�s O � �- subgests;�ie ee�&cw�s sa�atiuml;�e„sday�sJ sna�ere rhs.�s ;.: . .._.. _.. _ s (jp . . �.. �. , - � ..� fiv�a,bastsdned.dnJr'arrfb5 J.. y� ,..a . ,, . .:.. . .. . .,.. .. ,. . . , ,., � _. .�.:: I,as ahe oam�e a t6ae�c�psxty wili des sfse a�ork,aad _,_.. : . . � .,'.: . ._ �.....•.: � :_� ..:., ' ihe s¢racture is aot ineended uz aEferxd far sel� ^. .. . . . ... . , .._ .. _: , .. .._ .. � . ...� . .. .... ....... . . ....�... � .�- � � ��-..�...:;. (S¢c. 7044.Bu.saness c�Profacsdr•u�ad¢:�'i�-"."osc- ;.. .. . . .. . .. � '< . . : : . ......_. _._. _ ._... .. __-,.._.. __'. . ..... � Sr¢ctorSL+.�_.: - rla t � ' -' `..,; , .... . - � u�sssc Law� es�n r�p Xy so Bsa o. qP �'.....- ._ _. ..... -.. .. . .. .. . .. � � , . .�:�� -' �.�....�'.. �proper8y wbo Eai3'r3s ar sn�sroz�vs tbemaa.a�who rd'oes .. . .... �. �.� � ', . . . ... .. .:r. �,.�...., �--. . . . . _. ..�... sncb wossL bdrn.ce J�roevded ebat sueh itasprosieraereis :.:� ,._,, . . :. .: .. .. . .. . . . .. . .. .. ... . ..... .. _,: . .: ;,�.,�,�. .. . ars'�ios-3�#ersd'e�or affes�jar s�3'e�3'f,erar�es�s, t�re "� _.. ............ .._._.... ... . . ..._.... . �;:.. . . . .� .. bcsitdaag ar improaiemext Ss sodd svltbcn osae yesa°of �:......... _ ._. ._ . .�'.. ��. _ __ . ... ... ;.:.;., - .. . . ...•� .,::^t�`:� � . �`� .. �torngdezdar& &5e �tuttesdu4Y�er wi7'6�La�e �d��beards� z .,.. -:- :.�,.. .' . -�a�.,:�j,� .-.,;;'.;S",�. .. � � uJPravixig�bat be did eaoE"�eai&d ar ita�rove for atis ;�:- . .__.,,... .. . .. .. _ ...... . . . .. . .. . .�� . . � ,. _ . .. ... .. ....�. '...�..:.. : .... . _..._.._ purpose of se�7e./ � - �'�..', ..�.: ' ., . . . . ... . ,..:..._ .. .. .. . . . .. . ..... . . . . . . . . , .. - ._ .- . . . . ... . ..� :, . . , -: ,. :. ,_. .f,. .. ,,.., ..,._. ��.. .. .. .. .,...... - �P7C£i]F�$97fY[�PP�CC _. F, , � � i�1 -. . .,a., :; >> ; , � :,_,��, ,:.... : B&_,P.�,.�oz rhis�easr,n_._� , . , - . . . ... _,..... . _.,.. . . _ ...... ....... .. . .,, . r _ _ - • �, . ._ ; ., ... _.._,�_...._.._._ _ ......._.._,_,..,_ _. _ ,. w �. . . I�ate _ .<. ,` �... . ., . ... . f�v. _ .., .__...__ _. m€te.�, , .�.� __--____._ ,_. __. _. . ._. 9N5lECT4&'S�FlOYES -. . . ., .. ._.. .,.. .. , .. .. ... .� . . . . .. : . . .. . . . _._.. . . . . _ ,.�......k..,.�. ,,..>.._.,b.w.n, . s�_<�.�, ,�.,.. , F':��^',. � . . , . . . . . . . .,.���_.. ,.�- ;m;,:�,�m...,w�e����.as�.eg�ffi,w�c�.Ma,�n:r.�„d-.M..L�v+` :,:p.�. ,..,:�. ,. . . _ . ._......_�.._. .. _. .._.. . .,_ . . . .- ;. �^;. . �: . . . .. . .. . , .. � . , .. . , .. . . � .. .,.. ,._ .. . _ _ � � �,.n . ,.� :,:� .. .. �..;.. ,r:� . .� . � .. . _.:'.. ��:': ,�`.:..� :. �.,.�.. .... . . _ . . . ..M� ..�...�.... ,..�b:,��e..,:�...w..,,.., , ,. . . ,. ..: .- . ;.. _s,. '. . � .. � � �. �'." � . '- . _ ..:..:.._ ... ����.. ...� .. ..�� ... :.�. .......: _ .. ,-.a�.a�a��sow...es...m.:�n.��.-.esus�rw:,���sa��.�,:a�.,,...::9- ..,. . .. . . .. .. . _ . _ . � r.� .`..' .. '��...w. ..xi::-',�, '.... :,«...,:...,.....�._...�� .. ..,.,__:. . r ss� ,,. � . ,.. � =. . . M .ed.:.:�,�: ��;;..�:�. .,...�s.... ..:,.;.� ..e�::::z ,..c-:. . .. . .<.�w... - . w.u„Avec.�.r�n�w+,r.n.',.!.a...�,.�..:.;-:.,Mr.a�, .... . .._ . .. .... .... . ... . ' ..___.._..�..�.,,._.,....,_..... ...,_,.._.........�. .. .. „ .. . , .. . . am+rma.�., ' �w... . .. . , .... ,. . , - ,._ .._�. . , : ' :.. : .. ��cuz�.:snr�tm¢c��s�tied�s.:.,�..>.�. . ... .. . ....... .. . . _ ., ,.. . ._. .... ., .,.. ... ,....��. .,��.. .�sv;.ac-w..s..a�.a+.�..�wk......r....,..,,....Fa..:....a,,..,..«K._.. . a..a..,���,-.... . .... . ....... . . ..._ : .. ...., -,..,,... . .. .. ., , , ... .. �'