Loading...
HomeMy WebLinkAbout1481A WORKERS'COMPENSATION DECIARATION I hereby affirm rhat I have ❑�ceriif�cate af consent to self, . � � ,� ��� , �. � �� . . � �'„. . � � ns�re,or a certificate of Workers'Compensotion Insurance,or �bnaa2o , - a c�Ytified�oP thereof(Sea 3800,La6 C.) =EB�B�RE�.8:8„ qpp���ATION -FO�R�PERMIT��- � - � � �� � � � ���� � ������ - Pol cy 1J Company .5''�. Ft1Y1C� , '�s . . .. ..,_.._, . .. . � . .,,- . . .. . . , ..,.... .. ,-+-� —'] ' �� SEWE - S� d E D SPOS L . - -- �,' lJ Cerhfie9 ' hereby turnished. . ` �-p COUNTY OF LOS ANGELES � BUCLDIN�AND SAFETY" "� ' " " "" �� x�Cerhfied copy is filed wilh}he county building inspeclipn . , , , , � '�'� Ctlepartmenl. �� Dafe $ 2� tg Applicam �+''�' .IDA't1 fOR APPLICANT 70 FILL Ih CONNECTION DATA ;. ,, , 'CERTIFICATE�I�P EX�lvlPTipN PROM�VJOkKERS' � awmiNc � - p � � ' ��' `COiV�PENSATION INSURANCE `'�� nooaess .J • stnrioN oevTH . �-(This section'need not be completed if ihe work involved 6y the �,nHHoiE REpERErvc� UPPER �� 'permi�is for one hundred dollars($100)or less.) iocaurv LOWER ' ,' . .: . . .. . , .. .. . NEAREST �, � TVPE OF CONNECfION �ry�TH FROM�. . .. . � I�cer'iify t6at���i ihe performdnce�ofthe�work for�which ihis caasss�. - r. cuaa vi �ti.:roa.�. � - ' permil is issued,I shall not employ ony person in any manner � , P.c NO. C` '��sb�as fo become subject ro the Workers'Compensation Laws. �� � (�*. C0.IMP.NO. JCB NO � T''6�+ �'�" ' _:.....,-'.,'�,:.... .,;�, .. ..:.�... ,. OWNER .'. �' .-� � . . .. . . . . MAII TRUNK PERMIT NO. ROAD PERMIT NO. Dare�� � �Appl cdni � �� auoaess ., . � � NOTICE�70 APPLICAt+iT. If,��after making�ihis"Ceiiificote Of � C17Y 1EL� AFFIpAVIt WAIVER EASEMENT REC1�Rp.INSTR.NO. OATE mpfion, qou should �become su6iact to ihe Workers' COV3. 1 8 $ � IEGAL ''�^pensatian provisions of ihe Labor code,you must forthwith '�ESCRIFiION LOT NO. HWY.OR ST.WIDENING � .nply with such provisions or this permit shnll be deemed 35754 � -'"revoked. ' e!oc�: TRACi STATEENCROACIIMENT - ��' � � NO.OF BL�GS. � PERMIT ND ' � �"- '� LItENSEp CONT'RACTORS DECLARATIO'll"� � . , , s¢e oF w^T Now oN ior � I hereby af4vm th�at I om(icensed ndei-proJ s o s`of Chapter usE OF �9 (commencing wiih Section 7d00)�of Division 3 of ihe Busi- euimiNcS CHnRGEs � � ness"and,Professions Code,and my iitense is in full force and � �� ��-eVfect. � cvNrRacrpa 'G+ mnNECTiov cn�acE FEE � .�.. _.. .. ... Y ... . . �y ... . � � �� LiCEnSeNUmber 474887 I.IC CIa55 CJ� qODRE55 82T2 W REIMBURSE.MENiFEE Q - Controtior FTGCII1cZYI� Date �/ZO/S6 aTv �l�C�, ,(���a. TELNO 714 9�Q-4429 DISTRICTNO GROUP MAP PROCESSEDBY U p EK PG G � J I am exempt under Sec. of the LA.Co. 51eeNSE NO. C1a55 G� � ._. .._ . . .-. _.:,.. . . . . r � � � - ha DESCRIPTIONOFWORK � ��f'��" PlumbingCodeand/or5ec. ofthe Fir�ni �'G;�.3/�� VALIDATIDN d '� �' - ' �, �' HOVSESEWERCONNEC'INGTO ' DATE ' PUBLICSEY/ER l� QO .. � B.�&P'.Code fOY ihe fO��OwiYlg IEOSOh _ _ SEPTIC TANK SEEGAGE��IT OR � '" ' -�� � . " ' � PITS AND:aR CRAINFIELD F'�`A� /J ? . Date � � ��� � HOUS?SEWERCONFIECINGTO " �� �v����y.-.r�%'°' " � �" � ' cRIVATE�iSPOSAI SYSTEM ' ' Signa}uYe � CONNEG'AD�ITIONAL BLDG.OR. � � � �� OWNER BUILbER�6ECLARA110N " -�- � NORK To House seweR'' ' � I hereby affvm that I�am exemp(from the Coniractor's License �"�"� �xTN���sSPooi oRYd�uAMni�HotE � � ��1 �' Law tor the following reason(SCC1On YO31.S,BUi5nes5 anCJ PIo- ALT'_R,REPAIR OR ABANOON NOUSE {_,,,� i, �; y � V %�`;IOnS COdE�' SEvVER OR DISPOSAI SVSTEM P� . � . . . � . , _ . .., . . �,� I,os�owrier of the property,ar my employees with wqges as � � <-[ �Q . fheir sole compensation,will do rhe work and ihe strucwre , is not�intended or offered for wle(Section 7044,Business ' � � - ' l ��7 v��. ' �and Professions,Code). OWNER'S Pe�mit g 1Q � ❑ I,as owner of the property,am ezdusively contracting w�th AUTFIORIZATION 70TAL RE€ 'Z Q L�'L��`r�'"'�6 � licensed COf11�aCf0�5 10 construct ihe project(Section 7�4Q, I HAVE AT iH15 JATE A CONiRACT W!TN THF HERE:N NAMED Cph'TRAC'OR TO Bus�iness ancJ Pro�ess ons Code) COYNER THE A90vE DESCRIBED EXISTING DWELL:NG TC,?HE PVB�C SEWER. � �- `CONSTI2UCTION�CENC3ING/XGENCY ���� �'���'�"�� � �� �/� ' I hereby affirm that�ihere �is a�consfrudion le dmg agency SIGNEDTHIS �AV F rT I � . � for the pe formance of the work for which ihis permit is �WNER OR y issued(Sec.'3097,Cid.C.1.-� ' �' " � ' owNezsnc N�'� �y �.1 � ' _ . . . ' . . . . � A��JRESS� Y�f, fa.d�' � � Lender's Name '.'.:.'' : . . .. . � . . .. . ;;. �:r: �. �..,. ..,. . . . Lender's Address . . � .� ,,.� .:. �..., � . . . � •:..... .. . .J..... �� �:;:: . ,:,..,,� ., ' . ... .. _ . . . � �I certify ihai I have read ihis appl�ica�ion and stote ihat fhe �� � � � � � � � � � � � above information is correci.I agree to comply with all Coonty ordinances ond 51ate laws regulating Plumbing and Sewers, and hereby authorize representatives of tFi's County�o enter � � " � � upbn the above-mentioned properry for inspecfion purpo5es. � ,.. . . .. .... . :� � . . : �. . ��y r. .:��. . .. ..,. , �.. .. .. .�. , �r.- .... � ., .�. ��.,. ... :.. '__�_""4 �v`^— �-^��1"�7Y .. ., . .. .. . , . . . .. . ,, Signature of Permitfee - Date SEE REVERSE FOR E%PLANA70RY LANGUAGE � � ', � a . . . . . .. .. .... .. '.. t �. r. . .. . . �, . i , �.,�,'.wan�....,•..,.-.w.«. � ��.,.:.«.:.� . . . �� . .... � : . , . s. . . ,�..,. . , .:: _ ,: ,; � ,� ��s -�.?� >... . .; awsw�cro�•s a�orfs -- �L�AI�It-�3iJILDIEEr Y3E�bARA'I'I(DN �� �..'� �'�. d w 4.. .. . e,., . .. '`=' •'- � c,-....-: .;,{.. . A��R�D`eaALS �OA1E !NSPECrOR'S SIGNATURE I�3L`YEDj�2f:L5ii Yyi&Z II 8Gl g!,^.QSSi�':��}�ypg�py�YY3CCOR'S � NEW HWSE SEWER -��,� � ���- � y— Licease Law for the#olYow9zig reason(Section 7031.5, - CONNECTADDITlDNpI i r� Buainess �Prafassiv9s: CaLe):Any cixp ar raeesay� .. BUIIDINGOR WORK ' WTIIC{l s¢�"dfY6S n psmrse.ao cooasa�uos.radser,...6sosprove. SEPTIC TANY.SEEF,PIT{5) . . .., IYEIDEPPi5J9r,�_�j��'S`.B'�,'�3Sf8k:8tdre��JAAOi.$U S�95Sf{2:{CR. .. aN�iors oRa.iNFittn � aLsm segcssv�es �be;epptscaxx far sttcb,,3erasst tc fiile m � �sseooi�.1 DRVWELL❑ � . . signed seateme^raa Sb�t�Se is iicet+sed pearuasot to t,he prorrisrorac af Pba�+rnYractu�'s Z.ec�.nse.�,aw fCba�53er$ ��:. AITER.REPAIR,SEWER UR �-�..'I � ' ' " �c6mfliCf86Y v,1cb Sertiou 7��i6�� ffis;.as5�3 o,F xbe � SEWAGE 0!SPOSAI SYS�M . � f OISCONNECTPiUGANp � +$1.fStriCSS 64��90f�¢SSeUY.t Cadej or tbea be rs 3:Y'Q/Apt ..� � . 3berejmm aaa xne�.sas f�r ahe atteged axaoas�Ytio».Any� �;:��� A9ANDONHOVSESEWER ' �� RAIXFILL SEPTIC?ANKS❑ . � � " •, ...•.,.. u9oGi$i696 L�j5eciiti�'031.3�y assz,y.app'lua�afof sperrala . .- SEEP,PR(5)❑ c�sroo�s❑ � sttbjeets¢�g:��s3xa�a€�,�cs�s�,�seatt;y nf�r�eet mare¢bcs�a �� .... . . .. ,.-, . �:•:�.� .. .- . ,� x , .... . fi�hur�dre�ddoilars;'.�SGG).: �...:.. . .. . .. .,._. .... �,� _. _ . ,�.. �.. ": :.�. , .. . - � . .::. , .- ..` .,_,, "'�. �. � ^ � � T,as fdae awnez uf�E�k�ay�ee tv'�`I do ate mork,aad � - ' : � .. ..1..�.�. ..:,.���; .�-`.`:('�• ' . . the steuccsre is nai i�te�naed sa�o�ffere3�ar�aale� E... ;. . , ... .. .� � .... ..._. �. .: .�..... �. . �. .�.�.,. ......iSec. 704$,bwyr�s,asaiF Profe.s'ayaiaa.s�nd��Td��-���- ���,. .. ��.�, ...,-...- ._. ..._ .. .. _ ... -�. . . �� tra'ttor°s L' ��Law da � i ��1� t �� of ;>. . - . . - .. .. . . . . . .� . .' ��_ ._ .�:'�:.��... � .. . . ... � . � propes°ty who �u8 :kds�a^r tm.�r»ves gefeon,.n�sd who does ,, . _,: ;i ' �= . . _...... . . ... . ._, ._._.._ . . .. . .... ..,..,,:., . .;,_. . . _ .. . . . � . , , .. ...... . ,... _ .. . ... .. . ... . ........ .. . . . . .. ....., ssee/i vrork 15�msalf proteds�3ba1 sueb sml5rouemsnPs r. �� � �.� ... oa offared fo�sale.df,hoaueves, s$a �. .... ._ . ..,. . . . . ,.'.,... _ ._. .. ... .....�� � . . , . . b.u8lditig9�er�ded�emerat�As x�oldi taiEbiw���y�og e�,�.i _ _ �.�. :. ar .. ..: .. �,.-�,� .� . ^ ,. ;..., �. � �� rnmpletrow. 3he�ottmer-beaildes�^aill bur�e tbe betr�avt .. ._.. . . . .. ... .._ .._ _ . . . .__ . �- � . ;� ' � ..:�, : _ .:.,, .. .�, . .x..:� - �'�' .. . � _ . ..� o,f provia�abaE!ie did tta¢irur"Id�r ir�roue}or tbe �._ . ... .. .. . .. . � . .. ... .. .... ... . . _ .: ...�, .- „-,. � ...�" - . T . �, � . .. ;• �; i ,,,'�'_�'e'_ '3�.. : l:.......... .... . .. . . . . .::.'.'. _. , . . .�'' , . . . . . �, ... . . , . ., -:, � � '. �)l/f�IOSC O 3AY6.. ,. .: -s.'T _ ,, _ . �.8ffi Cxe��s't E�xf.�eC`.,�ts'�._.. s _ � , ., ° Q ._r,_ ;>.<.., ���.+�,.#or s�is re�saa ; �. . � � � �• . .._ :< .. ..._._ .._... .....�-;. ' � _ ._ . . . . � , . _ ... . . . . � - . � . � , � . . .,.,�. � � �- ' , ' ,.��_.... :_. .. .. ... . .. �.,. . �, ... ..... ..... �. _ _ .. . . .>� ��4� . . ... . . _ . ... . . .��_ ' . `. . . . -. . - , :, . ... , ... - . ._, . . ..{�4VII8T .. . - . . . '.,:_....-�..- - �. . . ':..�. �. �', ��. . . .�:;. . .. .. ,. ' ._..�. . . . . �....:': .. . ..., _ ,.. . .._. ... . . _ .,.. .. .. . ,.. .-.� � , � OSiSPECYOR$P107ffS . . . .. � ... . . . .Y, . . . . .. . . ....... . .�.� : . � -_ ', � . . _,x . . .,,....,. .�.., .. ,_ ... .. .� -' -.� -. .. � .- , .. . . ,. , . , , . - .. .� ,..,. - ......... ..,,- �.. „� ..;.,._-.�. ._:;f.., 1 ,` .., . _ . ..............__._.,,_......,..-...�+-�,.,-��,.•r+.:�-r. � .. .-«-w.., _,._.., ......_..._._..._ , ' t- ``:• �' . � � :r ,' ,. . . . .. , , . , . '.� .. . . .....�. ,...... .�.�. . ,,.._. . . , .3�f ,. rv . ._ . .. .. . ,, . , _ . . .,.r. .:«- .... . .i. � . .. . .. . �: ..�_�... .�.�,a .. .. „� , . ., e. .... .... .� .. , .. . ...._ . , .. . . - ' ' ;s..r .�..�,". . , ':':.xa u_..�'�...r i :..: .. , ".'� .m ... , . .. ... , ., . � . . _ .. .... ... .. .. .. .. ...........-.. .._. ., _ .. ,. . ,. _ . ., . . _ . . . '. . "_H' . m.q.s-.... . . ,..-v.n .v .. . . .;n ,w....... .