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HomeMy WebLinkAbout1539A (9) � . . .:... � -:: -�......,....�... __... ,..,. . ....._ .___'.. . - { WORKERS'GOMPENSATION DECLARATION � � � � �- � � � o�'� � � .-...... �. .... - ..: . .. . . . Pol<y N� affirm that ICh�an'vPp�certifimte of consent to self � �� � '� � � Y . . . .. ,. .�. ' nsu e,or o tertificote of Warkers Compenwtion Insurance.�or ��� �dAeezo . � � - � ' � a ce rified r' f(Sec.�360Q b�C ce aoe iaev.a�ei� . . . .._,..... ,. _.........._.,.:...... . _.,.... �a e Fund �� APPLiCATION FOR PE`I�MiT / .. tAd�r �...� ❑,Certifi:d"c�ish rebyfurnished _.. . ' . . ... `...��EYYC� " SEIN�GE�DCS�'b�"�'i����m�µ . .�-�.µ..^..--«_.....�..•.�-�. . . � � .. .. .. ,_: . . . . . . . .... _. . . . . .. .... ... . . . .. . py y g inspedion COUNTY OF LOS ANGECES BUILDII�G AND SA�ETY � "`�'" ` � ` " � �Certified co is filed with the muM 6uildin � � „�department . , , .. .......... ....,.. . ...... . .. _....._ �._....... ' ome 8 2��App1 cant T F'�2@lri3ri , FOR APP�ICANT TO PILL IN CONNECTION DATA "rCERTIXIC,4TE bF EXE/JCP`TION R�YJi�'4J��2KEFF5-��` � � �� � � suaow� - _6 CO/o{PENSATION INSUfF,4tJCE ' ��� � " � nooREss y�� sro.Tioni � . . oevTH �.:(This sedion need not be completed if ihe work�involved 6y the � uvPee LOCALIIY DIAMOND BAR MANHOLE REFERENCE ���-"pe�mii is for one hundred�dollors($100)or less.) �� �owek ' ' ' '' ' ��-� "� ' NFAREST TYPE OF CONNECTION �ENGTH iROM ��I certify thal in Ihe performance of ffie work for�which �his � czoss sr. v. cueg P.L. M.L TO P.t. '�permi(is issued,I shall not employ any person in ony manner ' so ds lo become;ubject to the Workers'Compensalion Laws. p �.0 NO. :f . �., :....,'..,:• . -' . ..:'.. .. . � ._._ . OWNER D Gil CO.IMC.NO. JOB�NO,�-(O L� � � �I� TRUNK PE2MIT NC. ROAD PERMIT NO. � �Daie,-�� . .. .APPlicant. . ,.. � .� . . � . . . no�tEess F ��i- 2 N�T�CE 7� f{�P�I�/(NT. �f, p{121 TOki�(� ihlS Ceriificate�of � -� 81�/pb��pC�l AFFIDAVIT WAIYER EASEMENT RECORD INSTR.NO. '�ATE C'Y Covi.na TEI.NO J �J „tiption yoo should hecome subjec7 to ihe Workers' �E�A� ��npensai on prov�sions of the labor code,you must forthwith oescaictioN iorNo. � nwv.oa sr.wioeNiHc __�nply with such provisions or ihis permit shall be deemed \� � � ��e'voked. eiocK T2aCT �. STAiE ENCROACHMEhT ' '.. ... '" . . . ......._".' NO.OP BLDGS . . ` GCEN5�D CONYRACT'O`I�'�D�ClRi2;671b'f5 '���- � PERmir No , ..... ,_ SIZEOFIOT NOW ON LOT � � i he eby aff m ihot I�om licensed under'provisions o(Chapter�� use oF � • 9 (mmmenc nq with Section 70�0)of Division 3 of the Busr , auuoiNcs e5�I�1� �.@ Residenee CHARGES ` ' ness and Profesvons Code,and my license is in full force and � CffeCt. �7 �7 CONTRACTOR CONNECTION CNARGE FEF ' ' r License Number � 4/48$1 ��c.c�ass_ C34� � nooaess REIMBURSEMENT fEE O , ConffaCfog FT'P_�RIDe3'Yl � Date�r�Q,���__ n DISTRICTNO, GROl1P MAP PROCESSE6'BY'�' V ' � ��Y t r�mAa TE:.NO. 1 O� G 9K PG Z ,;.:, ❑ I am exempt under Sec. � � o!the L.A.Co. ��yse No. 4 1 YSS7 aAss C 3� �� " O � - � � �O OESCRIPTION OF WORK FEE� ~ Plumb�ng�Codeand/or5ec. � � � � - � � ofihe�- ���� cin;n� U ' ' � � �' �'� ' '_,� � ' ��� � � ' � `� -, FYJUSE SEWER CONNECTING TO� ' ' ' ' DAiE VALID TION W � B:���&�P'Code for the following reason��� - ' vueuc seweR I����_� y - : . ' -� � � $EPTIC TANK,SEEPACiE GIT pR � - FINAL ^� ' Z DO12� � - � ' PITSAN�/ORDRAWFIEtD � Bv K .. ., � � � � �� HOUSESEWERCONNECTING,TO ' � � ' ' � ' � PR�yp+E DISPOSAL SYSfE " "' ' . $IgnotU e ..'YJNNECT ADDITI�NAL 9L�G OR '' ' '� � � �' . �OWNER BUICDER bECLARATIZS�" ���"-�"` "`"'"� woeK To Haus�sewea ��..� . OVERFLOWSEEPAGEPIT,DRAINFEtD ' . I hereby affirm tFoi I am exempi from ihe�Contracto's License " exTN_[ESSa00�,�RVWeu,MnhHote � �for the following reason($ecton 7037.5,Buisness and Pro- nt*ex eeanik ok nsANoorl HouSe " ' � � � lons COde): SFNER OR DISPOSA!SVSTEM .�:� :,;e,S'{{ . ... .. , . . ... . :.. � :.... ... . .. .... . . .-I,as owner oi the�property,or my employees with woges as },a .. s. c jO �iheir sole compensation,will do the work and the structure � � �.is not intended or offered for sole�Section 7044,Business ; .�, „����v '� and Pro�essions Codel.�-� �' � GWNER'S PBrmit g ❑I,as owner of ihe property,am exdusively contrading with AUTHORIZATION� TOTAL I'EE '�'7 Q - � :.[(,;:�:u licensed contrpctors to conslruct the projeU(Section 7044, � I hqvE AT 1H�s care n mNTRAcr w�tH rHE HEaE�NTJqA1Eo CONraAOOR te " ""' BUSin055 On(J PIOf25SiOn5 COdCJ CONNECT iHE ABOVE DESCRIBED EXISTING DWELL�NG i'J THE'GU2LIC SEYJER: r ����,G l'�.a � � CONSTR"UCTION"IENDING�RGENCY��" '��"� �'�`-"'���"'�'""� �'� y &� . I hereby affirm that Yhere is a construclion lending agency SIGNEDTHIS '�� DAYOF �� �q�" � for the performance of ihe�work for which �his permit,is owNeaoa , issued(Sec.3097,Civ.C.). owNeesr��eNr . . � . � . . ,. . nooaess " Lender's Name . .. . . . . , . �. - ,, , . .: � . .... Lender'sAddres's. .. _ ..� . . ,. ..._ ... : ..� .i..:. �..•;. .��. _ '... ... . . . . . . . .. . , ., . . . � . ,.. , _: , . . .... . . , ...... .� � �� I'certify�thdt f��have�read fhis application and state that the � . . ..�.. .� .. ..:�. .. .� . . . .. . . . . . . . .. �.. ,. . . � . . . � ' ""'?ibove informahon is correct.I agree to comp�y with aIl Coumy � orainonces and Sfote lows regulating Plumbing and Sewars, ' "and hereby a�thorize represemativas of this Courity to�enter �� � �� - � - � � �� �� � '- � � 'up'an ihe abo�e-meniioned propeny for inspedion purposes. � � � �AtNI �41vV1 r.vL� .�r"'.�-}-�� „ ,.,_,,, Signaf eof� Date � SEEREVERSEFO�RE%PSANA'IORYLANGl1AGE � � � � .. .^^^^.^ . � . �, '.��:.�.:.:.r...� .,. . . . ; . . ' - - .,�ws�s:=3�.:.e�.4u-'..:"iv++.+,��...+..�..::::::..,»�,:......:��s_cs:�.:r .,.._ '.�`.s:'r:...�.. .. F . _.-..._.... ... ..:.. .. ._. ,. �. . � . . .. .; . �.-,; ^ - .'s•4 '9 .. . ,.;,-.�s9 IT➢SPECSOR'S P60TES� ... � .. ._...v.:.�. . �DF�N�I$.�CI$LI9��,A}E�I.t4�'iTY�:�i �. � S.n�4 �� .r �,: T ' fi .r�. ...: .,. �... .. .,. , . .. ... ...5.... ; '.lvS>a1� ...,......Y'.. . . . ' .. . . . .0 . . . . z �.� . .. . ����O�AL� DA7E . INSVECiOR'S SI�NA'TUR'E� . . � �... .... .. . „_ I BICiE�8f{(YLR Y95HY d$f11 EAN�I�d:YlTif1 Y�N COfiSC9CT6f'6 _ E,icense Law tor�€be 4n1(owing reasan ESeca%aas 7a3A.S, iJEWHOUSEbEWErz � __ - ... � B#5s]SetS arud Fraje�-s9a�s C��r Any ea.ty ar coes:a�y mN�crnoortioNa� � . � . � V - �� � � � � wbdcb r¢gssis�es a permit ao consgruct,mdter,xa�rave, ' BUILDING OR WORK devMolisb,ov'repraes zray strxacaura,g>rtor ta,d�^tasuance, gPTIC TANK,SEEY,PIT(5) � qLtO re-eeir�s 2he dscaaac Lr�suc& vraia ao Lte a � pN�/OR'JRAINF:EtD . . .. .•. . . . 4 �P '" .1� 1` ` cessvoa�❑ oRvwEu❑ , � . .'. _,:, - ........,.fsgsed seatame€aa 2baa $ae 4s 8fsensed}wssuant.ro tba . YW -� . ,..,. ..r.,.i......... .:...... . .... . ' ' ' fs1POS113WeJ%O�3�96(�+096E555C8GT3�iC6NS6�.fsYU r�.aM�EEf� ALiER,REPAIR,SEWER O2 f ��- ' {COfIlq38�YCbf3g YUSEIY SCt4iCi1]C�Qf Df�1T/PShC9d�Of 3lf2 ���' SEWAGEOISPOSALSYSTEM � . , _,. . _ . � ""._.... . . - - - Bussxess and Professiors v'�ade�or thad ke:is zxem/rt � oixor�wecr vwc nNo - ' iberefrom axd s3ae basds far tbe aldeged exeuapNorr.Rny A&1M�ON HOl15E SEWER �� � • ' '.� .. .. ..�. .�. • ...-. �•• . . ..••��.•..."",� 'VEOt62fOfl Df SBC�6T.JOST.,S FIY�;1�APPrfC6f%2,fOPU�2Pl9i:S BAIXFILL SFP'f1C TANKS❑ � . � . : ffEF,PIT 5'❑ CESSVOOLS❑ _ � ' :• . ^ JI,JE LS YIS¢tlfT,�it3G095 a e¢v5��ClEEW6JEj+'oj 330£ftPQTE 4Sd0E , .,.,._... ---... . ._..� �...:.,.,. _.. ,.,...�_,-_._......,,.... -+t.�. .�,._.,.:..., - � .�:,. _.... ,,.......,..,j�bmsdred doTlars�S300i�; '��.. . _.. .,.. . .... . . . 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