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HomeMy WebLinkAbout1538A �-_- _. . .. _ . _ _ I WORKERS'COMPENSATION DECLARATI'ON� - �� �� , ., , , . . ; .- . - � � � � - �� � - ' ' � � I hereby afflrm �hat�I hove o certifimte of consent to self ' _. . � nsure,or o certificate of Workers'Compensafion Insurdnce,or - �anbaz0 . - . . a eerfified ih r of(Sec.3600,Lab C.� ce9oBieEv:aisil""�" � �pp��sCp,�60N -�OR P�R��fi�-������ �� ' ���� � � Pol.<yNo=����ompan,State Fund �Vs �.A..� p ���y ...�y��i' q y�^ _-... ... .. ._�..." .. . . 7❑�Certifi�reby furnlshed. SEY■ER ' ��YY�GE VIJ�L�f1l . . . .. .. _ _ - �� �J Certified,topy�s filed wilh the county building inspection COUNTY Of LOS ANGElES -� BUILDIFrG A�flb$AFETY�- ..��-;_dePartmeN. . . . . . . .. _.. , .._,... . , . , . ...W,..d. .+ � .. , .._.' ....-_.... : ._ . . ...... '- oare ZO SF)qpplicanf �. �'reem�Tl FOR APPLICANT TO FICLIN CONNECTION DK7A , ,�, ;:. ;., a .:.:.._:.. ���CERTIFI�ATE Of EXEh`IT�TIO.uy'FY�O�W(3�1��'I�S�'., euaoiN� [� � sTnnora oe�*H � --�:�COtvt�ENSATION INSURANCE � �ooae55 .7 �� - � (Th,s sect on need not be completed if the work involved by the ,L�ii*r '� nnarvNoie aeFeaeNce uP'ER LOWER .. ._ . .. ... � perm i is for one hund e dollors($i00)of�e55.) NEARESi TYPEOFCONNECf1�F1 '- IFNGTHFROM ' . . . . ...... ..... . .. . - � �I ce��lfy�tHat in the performance of�the work for�which this cz�ss � r c�ae. v�_ .N.i.roP.�. �" permii is`issoed, I shall not employ any person in any manner a c.No µJ��`i� so os to 6ecome subiect to ihe Workers'Compensation Laws. �wNFR THLi' �QD�`+�T (�'1{Q� co.inna.rvo. �oe ro.- . ., ., ....�... �.r.� �:,^r: .•.' .. : ... . � .......,.___... .:�. ., ,. �. . ..-- MAIL � , . -� ' � � ' � A�ORE$$ ' iRUNK PERMIT NJ ROAO PERMIi N�O Dote A pl cant .. .. . . . �. ....,. ". ..,, P ,., �, ,.�a.. ,. '_:..,t ..p;.. ' _�•.,,,� AFFIDAVIT 1NAIVER EASEMENT 2ECORD,:N5TR.N0. CAiE NQTIC�"TO ��PPL�CANT I(,affer making this Cerfificate o��� �iTy � CiQv��A ,E�.No. 818/9d7-954� .,Srs.ap�nplion, you should become subject to ihe Wo�kers' ' ' f npe�sation provisions of rhe La6or code,you must forthwith oesccivi�ioa � ��T�No� �' HW�.OR Si.WIDENING Mply w th such prowvons or 1h s permif sholl be deemed . - �� 6tOCit TRACT � STATE ENCROACH/dENT" � - �-'�"'�'��� f0 olteC�. �. : . .. .."..;., .::.: ' PERMIT NO. .,..., ..,.. ..�, . � . NO.OF BLDGS.� � ' , ���.'�,LICENSED COMR"P.`CYOk�"tS�CCA7�A1`�a�"����� _ . sizeociot now on�io- � � _ . ;;' I hereby affirm�ihat I om licensed under provisions of Chapter� use oF -������' " "� �� - � 9 jcommencng with Sedion�70bb�"oT��Division 3 of ihe Busi- BUILDINGS ,� eNnrt�s _ _ - ���n'ess ohd Professions Code,and my license s in iull iorce and - ��- �� . _ ...,_.- - � . effect � � Ary,1 �.7 �,; .,;,,, , �., . .. coNraactoa DISTRECTIO"1 Ch1ARGE FEE � ' ��' } license Number '4 1 Y$8! L c Closs�+ � ADDRE55 ��� ' e (,'� REIMBURSEMENT FFE ` T Freeman 8 20 86 /�, p 0 714/980`�4�Z J ICT NO. GROUP h1qP PROCESSED BV V COM�OC�Of �o�e CITY ti.ita Zd�a'1EL.N0. gK pG o _ _ .. ; - STAT� 4 4 ���. C34 �� ❑ I am exempt�nder Sec. of the L A Co. - , i,rENse n�o aass . Plumbin9Codeand/orSec. oFthe�� NO- DESCRIPTIONOFWORK � � �� FEE��� ��Nq� � . , .IOJSE SEWER CONNECTING"O DATE ���^J`O� VALI ATION , y � 8.�&��P Code for ihe fofloJ✓ing reason � � � PUB��.csewek ! 0 , SEPTIC TANK SEE�AGE PIT DR , . . . FINAL � . . . � ' .�Date ... . . ' '.. PIiS ANO!OR�RAI�FIELb . . . ... B� �/' - - ��oUSF SEWE2 COIJNE�ING 1�3' � �, � �� , . , , . � � , . ' . FRNATE DiSK?SAL SYSTEhl' $gnOtuf2 ; CCNNEG7 A�011pNAL BLDG.6R , � � ��� ` °' OWNER-BUILDER;DE'CCAR7(`fItYN �����"�� � noarc•�Noose sewea -� OVERF.OW SEEPAGE olT,DRAINFIEL� I hereby aff rm that I am exempt from Ihe Cont adar's L cense� � exru __ssaeo�,oa�+wEu,wa.Nko�e � Law for.�he following�eason(Secion 703i.5 Buisness and Pro- n�iea Recae oz ner.n�odv House . . ,l�'�'+iOnS COdE�: SEWER DR DISPOSAl 51'S7Ffa� � � ���� .I,os owner of�he properfy,or my employees with wages as . ° � •- ° 1 ti � their so�e compensation,will do ihe work ond ihe strycture is nof intended or offered for sale(Secilon 7044;��Business O�NE�,$ Permit S �„{3 Q � " �� f'���"� �� ond Professions CodeJ. ❑�,as owner of rhe properfy,am ezciusively conrrocting wlih AUTHOK(ZATIQN TOSAL FEE 'L7 � - - '��l,�%i%�%' �� licensed contraciors fo consiruct ihe projecf(Section 7044, - � i rpve nr THis oA�n CCNrRACT'�i?u THE NeREw"Nn'hnE�forviRn[*na,To BUS� eS5 4nC�Pfo4e551anS�CotIeJ. GONNECT THE nBOVE�ESCRIBEC E%f$IING�WELI:NG YO�THE PUBLI�S..M;ER. �� '1�;��� ;�� ' �� � �CONSTRUCTION�LENDING AGENCY �'" � , I hereby affirm tf�at ihere it a conslruction lending agency � SIGNEDTHIS�.�OAVOf ��9_ for ihe erformance of 9he work for which this ermit s OwNeeoe � ,/ .. . p ..............._........_... P �� nWNERS AGENi C`IO'Wl_G.-� Cf'�� — .� iesued_(Sec 30�7,�Civ.'C�.�.���� . . . .. . . .. . .... . . A�DRESS _. .�Lender's Name. . . . .._...... � . � .. . .... .... . .. . . . . . . . . . ,. �� ... .. .... .:.... . .. . �::.- ', . ..;_ ..i . .<_ � . .. ... . . . . , . . . . � . _....... ..._. ,.:• F :,:, .i..,-r.., ., . . . ....'..: . '- '.�..� . .,.,: - . . ....�.. � . �� .._.._.... ...... ... ,........ _ ..,.�... ...._.... .,....... . . . � Lender's Add ess . ��.�•,y�'���.A•. .�.•.•..M.� �~„�. . . .. . _ ,,,... ,. ...,._,,.,. __.,...,....-....,..,.�_».,.�...«..... , 1 certify thaf I hove read��this application and stote that ihe � . ' � �obove In4ormaYion is correct.1 agree to comply with all County oidinances and Stofe lows regulating Plumbing and Sewers, . � �.� �and he�eby authorize representorives at this Counry to enter - �upon the above-menrioned properry for inspection p�rpos'es. ,, _..�,.:. 8/20/86 . . � � Signofure f Permittee Dore SEE REVERSE FOR EXPLANAYORY LKNGqKGE ��- _ . _,__ .. .. .� . , . . �.> ....: ..:;: .r_ „ - , . . , . �.. ..... � ..:._,' ,,. , ,.... ,_ ..__._ .._ .. .,...:... , , . , � -�. .-.;<�r t- _d:::. .,.q,a,: : � � � , �,; � s .:`�IN65P�TAR'S NOY�...... �yy}y�.y� �-� a r':. , , ;ri .. � ._ ..��_ __ A2' b3��'It�E�I.t4�'�'��hT . . , . .,�� ., ,.,-..a+_,�.,...v..i . ,.. . . „ ,. . . .. , .,..y... ... � S3S ll�!Yl�s3m��3�r� _..A...';s.�� 'v�:.i-:.. ._-'"�`--.._ _. . ...� � . ....�i.._� - Pe�PROVALS DAIE INSPECfOR'S 516NATURE. ' � " � ' ` __ S�P1'ESp 63fYPriR 7St&E F BYR 2RL4��i/8�Si.R�:I3e CQPELA'$L$6'_'�S NEW HpUSE'aEVJER � � � � "� � -�-' �icense�:aw far x�e taF6oaing seasce�S�stBrora lf331.3. . . _ Brs,sRnesa umd Psqfsss#nres CmrBs}:�ssy ss`ey or r.ous:ty ._._.._�� �. ____ - . � ...... .........._.._,. ......�........ � ' CONNEC4ADDITICNVAL.. . . .. . - � "- '91ifDeC�.^TBqi6C£P4 2 gETB�iG ib cYiYfSE/YCGt 18xt�i t99�lPYiLB� ,� BUILOING DR\NORK " . � 132)NbrfS}S.e3T YSU�SS':.Yny 5$YkCi3iY8r. �-f'�YY'�&3'935dftY..t@� SEPfIC TANK.SEEP.PIT($}.. :."' . . . .....+v.....µ...,.. ; AND/OR DRAINFIEIA . ............ .....•.. .....•,._•,.�.••.SIbO TElfN3TER $AM G�IfCb�t fM'3idY�J�'lR9Y78C$EJ�ISIe¢ .,. _ .. .. . � � ' _ sdgv+ed szateneessss t3aas ne x�:dsesu¢�' urseaasat to ebs � " �ssvooi O -�onvwEu a .. , ..,..,�. _. .,�....... ..,.-.....,:... ..:,.... �... ... ... �.-....��noisions�af tbe Ca�.`�-astor's Licamsa Gaeu f�hupCer 9 . ALTER,REPAIR.SEWEA OR ^ ... . {(.'pryy�8d36Y�A6 wria,&Ssr,tea�.7UaU%o}B3irs±sxoaa 3 of tbe SEWAGE OISPOSqt SYSiEM '.i�,.� �, , tl0 . '. ._. .__._._:....�._........._.....,-...,�.....�:....,�......,�,..�,,.._.... BrusSrsass�ad'Pr�o�`erasrssw CG+lej or Sbnt:"9E ss ax8mpt . OISCONNECf PIUG AND ' L'fJBfE Ai dSPB¢:3jle I)JdFPs'df EJg¢�FFTe el�gY¢?fg�¢fO7M AfS ABAN�ON HOU.E SEWER . . • . . ..._ �. .. ,I G' "{y ,'Y . .. . ......e�:.�.. . . .�;'- encocFiuserrieTaNicsp� - .., . � .. �, ,.... . .,..`., vio7atiouz;7Sart3rna7�3Y.53�yaayrt�lsl;ca�sJvs¢�e�avre=t SEEP.PIT S)❑ eessroois❑ 4 .. . .. .- subjests�bn�pldcsr:f CG a rl�f,�att�ay uf xoP�nvc-�a� �� . .,.,_.:.. . � �,. �.. ,�...:�-� ..,;.,y. . ,..... .,,,,.,. ,.r.x,��aa�_- ��.�tm �� t�.:....,.r .. ._, ,::.�E�be�advea•'ado4o°cs�s�i'�,4'St7i3I.: �,', ... . ... . . �. . .. . . . . . . . _ .. .. . � . .� .. Y,aa ikse�anmecer a�.he 3e�pssfi��wi35'o's�.e eerork,saei ��>. . ,. .. ..: _.. 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