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HomeMy WebLinkAbout1483A WORKERS'COMPENSATION DECLARATION I hereby affirm that f have a cerrificote of�consenP��io�self � , , � � insure,or o certifimte of Workers'Compensation Insurance,or ��abn7o 'o'ceriified,�aax�(5ec.3800,��;.Jn�� '�E�B(REV.B/81j APPLICATlON FOR� �PERMIT� - - � �Poficy No. Company '� OOs � "- �'p SEWER - SEWA+GE DISPOSAL � �� ❑Ce tfi,_,d_ o � s hLsreby fumished. ' � C�UNTY OF COS ANGELES $OILDING AIVD SAFETV �ernfied copy is filed wiih ihe wumy building inspedion _ ' departmen't. d'ai'e�$6ppHcant�o9sa�_ FOR APPLICANT TO FILL IN CONNECTION DATA „ ;�C�ERPIFICATE�OF EXENiP'tION FROhI�^IORKERS' ' y�aoiN� ��, / `'COfNPENSATI'ON�INSURATI�E � �" �- ' nooaEss fy� sranoN oerTr+ � (This secti�on need nqt be completed if ihe�wark In4olVed by tltE � MANHOLE REFERENGE UPCER , perm tls for one hondred dollors($160)or less J �OCALIiY LOWER nEAREST P iVGE Of CONNECTION IENGTH FROM �� I certify�thar�in��ihe���peifoimance of the�work�for which this � ce0555r. °� Y. CURB P.l �^4.LTOP.L. �permit is issued,I shall noi employ any person in any manner - �� so'as to become su6'ect ro the Workers'Com ensation Laws. �� �� � - v c No. J� � . , ;,:,, „�I� . P �WNER �D � CC.IMP NO. JOB NO. V�� � � ' ' � � - ' A�DRE55 .GMJ �Y�l/1L y TRUNN FERMIT NO. ROA�?ERMIT I�q. Da1e - ApPlicant� �� p `� -'��' �''�� ' ' ; ' � � ��• .-� .� . AFFIDAVIT WAIVER EASEMENT RECORD.iNSTR.NO. DATE . NOTICE TO ftPPLICANY�i If, after making ihis Certifimte of� �.t� �%Q'Z7'],]`le','�„ TE�.No. 8�.$ �j �, ,?rcemption, you should 6ecome subjecf to the Workers' tecni � �� � npensation provisions of the Labor code,you must forthwith DF.SCRIPTION �O7N0. Mwr oa sr.wioeNw� .nply with such provisions or this permit sholl be deemed �� �revoked. s�ocK TRACT STA?E EN�ROACHMENi � � LICENSE�D CONTRA�T0125 DECLARATION"' '- Nc.oF �o�s. PERmit n'°. ' � S�ZE OF lOT NOW ON tOT� ��l"hereby�6ffirm that I am�(icensed under provisions�of Chapter � uSEoc - � 9(mmmencinq with Section 7000)of Division 3 of ihe Busi- , euimwcs 5'1I1 cn.ae�e5 - � n'e3s�and Professfons Code,and my license is in full force and ' e�feft. , � COMRACTOR ' ' CONNECTION CHARGE FEE A�J�7 (��/ ,,,.�...,.. } �� � L cense�NumberY I'�h�[7 1 �C ��p55 ����+ � 822 ' - ' REIMBURSEMENT FEE � A�URE55 Coniroctor FY'EA111311� ��Dote R/�n�}��i .YJ.yC7. I,oma. �E�No�� 1 . gp� ��ISTRI�TNO. vROUP MAP PROCESSEDBV V . . . �,_. . . ----P---�- CITV BC PG Z � ❑I am exem t under5ec.�� �of ihe l.A.Co. � SrqrE p uC o P � . ICENSE NQ (,�� CLA55 �!� F - ' ' "�� � � NO. DESCRIPfIONOF�WORK� FEE-' � Pl�mbingCodeand/orSec. ofihe �� :iNni ' V •' ... _- . .'- ', Fql15E SEVJER�CONNECTING TO ��� � ' � DATE �� �i �� VqLIDATION d � �' � '" � ' � � PJBLIC SEWER - . B &P.Code for the following eason � �� - . . Z 'EPTIC TANK SEEPAGE PIT OR ' .. ' PIiS AND/OI�DRAINFlELD ' FlNAL � , , - D��e NOUSESEWERCANNEC'�NG?O ' g� - ' . .. .: ' .. . ."�. � PRI�'ATE DISPOSPL SYSTEM � $IyntlfUlC � "ONNECTADDITIONALBLDG.OR � ► ' ��'�� � OWNERBUILDERbECLARATfON �� � `woaeroHousese,vea ' � � I hereby affvm�t6af I�am�ezempt from ihe�CoMractor's�LiEense ��,"� eziNF��e95P O[GORvwoRANaNHO�E Law for the following rEo50n($ECfOn 7031.5,BuiSne55 Ond P�o- Ai�ER,REPAIR OR ABANDON HOUSE � JbA^ O 5�COCIeJ: ' SEWER OR DISPOSAL SYSTEM p� .'`.r . , :.. , .. _ . ?-i �, a W F1 � 1,as owner of rhe�p�operty,or my employees wi�h wages as� Iheir sole tompensation,will do ihe work pnd the siructure r. � *` S� ',�i is not inrended or offered to,r sale(Secfion 7044,Business � ' ''� �and Professions Code). � OWNER�$ Permit S � �'� '�:.J � ❑I,as owner of the property,am exdusively comracting with AUTHORIZATION TOTAI FEE `Z�(" �j� - . . � licensed controctors to,consiru<t the project($eCfiOn 7044,� � I HAVE AT TH!5 DAiE.4 CONTRACT WITH TNE HfREIN NAMEO COYTRAROR TO �"� �� � "v�/� BU5in655 Onc�PI'OfC5510n5.COCIB) CONNEC7 THE ABOVE DESCRIBEO E%iSTING DWEL�ING TO THE PUBLIC SEWER - - CONSTRUCTION LENDfNG�AGENCV ' - ('�� :^'����`�'� I hereby a4frm ihat fhere is a consfruction lendinq agency SIGNE�THIS�DAY F O 19� � OWNER OR �� � for the performance of the work for which �his permit i5 OWNERSAQENi_ �� � issued(Sec.3097,Civ.C.). . , . . . � .. . FooRess� � � � Lender's-Nome� � � � � . . � . ..;,:., .... �. . � . . ...... ..._.: .. , � . .- .-,' ., .' ,.. .,: .. . . � .�., ,..�. . .,.>. . �.:,�, .:. .,..-� . .. . . . ..'.�.� . . .-...-.. _ ,..:.�. �.... .... . ..:.::�. ..:�...�'..... � .. :,.. . . . ... .- ..:_:�, ..�.'..✓...- � .,, Lender's Address � . �_ , . . . � � . � . I certify that�I have read this application and store iha�the � � � � � � � � � . '�''66ove information is correct.I ogree to comply with all County � � � ordinances�ancl�5fd(e�Idws��regulating Plumbing and Sewers, - � 'pnd hereby authorize representatives of th�is County to enter� � � , - � � �- - � �� � � �upori the above-mentioned properfy for inspection purposes. � � � ... ... ..:.:, � ..... .... ....�.:::' ..:..,.. �.::... .' ' . . . .. � ._. . .. . ... . ....... . .......... . . _ ...,...:.... . . � .:.,� _ ..�� ._.,_ �.,..,.. ._.. ... .... ............ . .... � ��_tww�vti--. $"�� $ignafure�ermittee Gate SEE REVEIISE FOR EXPLANATORY LANGUAGE � 4 t � ; stasPEc�oe�s a�aE�S t�°yVri'�Ft]giJIL°saE18�3�,C�. �A'i'iO1�I. '<�i.'�3,'.a"s � ,a a .. , .., . .,. . � . .. , �., " . .. . _� ���i��V�6S DHTE ' INSPECTOR551CaNATURE I�4C1'Q'�Yy'6�E£�'Y�i&t.x-BUlE��'p:�YJ;[P`i0'COR'742ELbt'S NEW HOUSf SEV/F.k ' €� �*�, � Lisanse Law Ycr the fioHlowing reas�a jSeciio��7D31S� ., coN�crnomnoNni _..i � Buslness an�ProfesrPoau Gadeir 9ay ci�y ar�.cmunsy `;2"' BUILOIPIC;OR IYORK which�rsgrisras a pesiiiit�sn snrssrrucs, aluzr, d»ay�ro�e, ': SEPfIC TANK,SEEP,PR(5)� [IeH80JGSJJ..or.repasr asay s3srsctttre:�r1or`Se�.sds iuuasace; � AN�/OR D9AINFIEID ' � 9Lttd seq�6oes'�abe applacrrns jcc saic&permffa to 3s.de a � sigraed staaemess3 tSaa he es PAr.."B#3etlY p78FYst1a99it 8a abe "B t cessvooi❑ oaywat❑ . . . ' j�rrovdsiosss of abe Go�ntructos"s%.ices�a I,aw jC}�aptes 9 0 0 ` ACTER,REPAIR,SEWER OR PCOmp36fYLY�g ul3t�S¢CtEO%�O(10,�o�.'�EslisiOri$o,f!'ye SfWAGE DISPOSAl5Y5T6Y1 ' � BrasBmes;snd�Professior�s Code)�cr E�ist ne is a:rempx � ne�ooN�i+ousE sEwER ' aherefrom asad iZrs Z+aers,}`mr sbe al4ege�e:semptfon._9ny . � encKFn i seanc TnN�cs❑ -- vfalatio�oj seczron 7037.5�','aan.i'a�Plican8for a�sefzni! -- SEEP,PIT(5:❑ cessroots❑ � `� � sz�b�ects�ie a�pdr"caHt:a n c�d+iiY,grenadPy af aaa8 mar¢tban �.�.. , - �� -�- �; ti�� , five bundv¢d�odtarr(�'Sf�OJ.: r ,. : . ,, ... .-......-: :.: .�, _._ . . ... . .... ._. . . .. . -. - �- - I,as sdte or+�ner�f ti�e r - "'t u P�e wo�k,anu . �r ..r �.-,:;...�� . 1,�� r.. ; � : . . -� .t�.`: ,..` ,':�,• . :�•;,, - � � t�struMurn is nce inxended ro�P'eted far seTe�� ,,._ . . _.� .._ ... _ . .. _. ...... . : . . . ....:: - � . , : . . , , ' .-_ �'Sec. 7�i¢4.Brasduess�nd Projesaeoas Code:7'"'".rfw . . . :: . . . .., .�.� .;;� , .' .� ..iraceor's.�ic�ariae�I,cu>do¢s saod��PfB,��to asc-oi .. �. :. . ;_. . ._ . . ... _ . ..... . . . . .. . . . . � � . "'.. . ....�.. . � . . ..... .. . . .. .-`" < .. , , prope�i�3�YllllO P13CfIXS OY 9�9f8p�Y0UE3 SXDCTSOFs orad who doea ... e' � �"=' :'�'..�.. . . . _ . . "� ..,� .. .�.�.. ... .. . .. .. mch work batrssedjy�ruvrded.abas sacb imi�i�irooemerats � ,. .. ... . . . . . .�. . . _ .. . . . � . � :, - �.. .. ��,.... ' . �'� .. �. � , are�aa'8 inien�ed�ar nffered,Jor saYe. d,g bowevee, tbe ��.. _. ... .. .. . ... ... ... _ . _ . .. ...; .. .. . &uildisa ar�dfa �vameak ze sold�ruxtbdx ame ¢ ,>a; ..,. �,. & P�'� 3' � ' ar .:... .... . ..__. . . . - ... . ... . . .. ... ;; -.- _... .. - _.... •-�� - " � � ^' .. . rompietrom. P&e owner�btta7der rvfll d�eve tbe buvdevx `:� �:.,:-_ ..�,:.` . .j� „,. .:-�. ,:F,t . . ...oj Arov°�2bmd&e did aaos 8s�1d or imprnve�'as sSe :. .. _.- --_. _ _.. ... ._. .__. _ _. _ . " purpose o saY�.,+ , 4 . .. ..0 - ._ . . _,_. . .. ,... .. .. . .... . . ._ -.'. .. .. . . _ .,. . . .L; � �- ... . . . ,: " . ; .' . _ � ,. .1�. .., � .,. . ._.,. ,.. . d fll�'i E 2ffijS$3tY1 ,. ,�'�--- s � �� .. . ., � . ... .. .. . . . . . ... . .�. . ... � �` r�- ,r,c�a H&P.C.$ai Ylli6 Yf�SOCA ... ,� , _. . . ,- ... � ��. -,.,:,,� ... . 1'late . . . . _. �, .. ,. . .�,s., , _: .. . . . _. . . . . ... ..... .. �, , . . ,, 1N�PESTOR'B NQFE§ . _ . __ ... _ .. . .. . ...... „-., . _ � _.. . . . ,. ,�r �,.�. . . . .. . ... .. .�...... . . . . . ._... _._....:...... , . . : _ • � . . , . . :. � . -, �, � . �. ,.,_� . . 1: 5.."i . , . . .. . . � . r . . � .. � � . - . . . . . . � . � . ,�, .. , �. . ..„ -..-, .. . _ . . ,. . . . .. . � -,:..: ....� . .,.. �. .. . �....,.. .. , -. . .. . ..__.. . _. .. ,....� ... ........._ . . ....._ .�.,.r; . , .. ,� �: .,�},'�. ,..,:�.,.�. . .�,. ,h �..�:. . ,.�.:..�.. raz�;:[cs�...<.'.;;.::.>..� :r-. .s�,:�':' ......... .. . __� . ..... ._. ... . . .. . .. . . ��.