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HomeMy WebLinkAbout1588A .. �� ''' � -y`�.Z<^.,�.. A.�a+ ,.,�.F.x-+'i��..�+x�,�C..�a.wr3k3za-r+�m�+ Ma�z�nie��e4� .�M,,y,:...�e��. _ >. .._ . � ., . . �.:. ...:� ,.;. ' � , WORKERS COMPENSATION DECIARATION � � �� -'� ' �"�� y� � �-. , , _ i �' . '�',� .�:; , . . .._....... .. ." - .. ,�.w,..=... �,�. �� - I hereby affirm thaf 1 ha4e a cetificate af consent ro self � '���'"`-"" �"-� """"� "�����•��-��-- ����� � � . . � �� - � .ma �..: .. ._ . __ . ,.. _ ._ ..,._._. ._.� ��_-. . � � _.. . _ _..... ..._.:. insu�e or o cerlificate of Workers'Compensaiion in`sur6nce,�or � "'��aa2o . . . dfeti��f ed � t f(Sec.380�,Lo C,) ce eae icev.eis�� �� � - Po��Y No.�-�Company s�, ��. �, APPLICATION FOR PERMIT Y--� . ,. _. . ... _ . � LI Ce nfied�. � �ereby furnished. � � � � � �S�W�R ' SEWAGE DISPOSAL � '"'�Cert fed copy is filed with the couMy b�ilding inspection COUNTY OF LOS ANGELES. , BUILDING AND SAFETY, depo t nent. C . . . ...... . .. .«. ,.. . .. .. y�o�e S ZO BUqPPlitanf T. Freeman FOR APPLICAPIT TO FIIL IN . �.�``�'. ""'"""'""` .:.: � CONNECTION DATA '� �ERTfFI�ATE OF EX�MPTION FROM WORKERS .. .�. � BuuoiN� /� .. . ,...� �' �� . . „_. ...... .�,;.�„�..... ,.,„,,. ° �COMPENSTT16N WSt��'AN�E �� �" �-"` ��"' nooaess � 1/� � __� STnrioN DEvrH � •E a <,., ,��,•�-eied`i iHe wo �nvol "Lc : , l [-V� (�c-"1fo (Yhis sect on need not be comp �� �`" "k �"'�aed by tfie� � � � � � � � uarea DIA BAA . _.�,..._�. .:.��,.,.,Ta, LpCALITY MANHOLE REFERfNCE '_ perrciil is for one,h ndrecl�dollprg,(5100)or less) ioweR � I cerfify�thoi��' p. � . � work for,wh ch Ih. �ARESr �� �� ... .' . .. . _..'.' irvEOFCONNECTiON..., ..."'•"` . ��he erformance of the �s cko5551. �► �E��o������ ^ peYrnit s ssued I sholl ot employ any pe son n any manner �� ��� �� ;i So as to become su6�ec1 ro the Wo ke s Compensation Laws owuee ��N�T'..�N (i� ��� Pc No`�"' P� : , ..,..:: �h4�.^' j '.,j .,'-� . . . CO IMP NO J08 NO. , '...,_..,:.. NJ�I. �/,�p. .. 3329,._. ' ' r�t�:•�..� PP ....�µ �:.• . . �..'� .�'. A'J O '.1.iV iRUNK PERMR ND. ' ,...• �•_R04�PERMIT NO�•..••�•••.•..••••:-.....wv � �qte A ricant ' ' DRE55 � A �:LL ...:;.. �� ���r��� � �"" �� ��� ���"�" ��""`""�' AFFIDAVIi WAIVER E45EMEN1 RECORD.INSTR NO. DATE � � 130TIC$ TO APNLI��NY� If ofter ma�ng t�is Cer'hfcate of � �iT� (�OVl� re�.No. � �"'s�pi on, you� s�iouid��become� subject to the Workers' � .. � . .. _„_ " `� .>aensation piovisions af the Labor code, ou must forthwith LEGP'� —�����—�-���--.. .....���......_......,.<,,......,, � �cari�°I wirh such Y oescaivrioN ioTNo. . py provivons�or rhis permir sholl be deemed 4 . . Nwr oesT wioeNiNc " ' `�lEv`Ok9d. BIOCK TRACi SfATE ENCROA[HMENT ... -. -•.._...""....•,•.•.`•.^.'"`"""""••'�, '- �" LICENSED CONTRACTORS DECLARATION�- �� �� ���No':oc azo�5. - � - �"' - ' - G�RMIT NO . S,.ZEOFLOT h'OWON1lOT ........._ ...<.....�.._�..:wwm:......��,,.r.�+...r . .. .,.. ..W. .,...,-: � • I hereby affirm�ihal I am licensed under provisions ot�Chopter� �SEO� ...... .._„,.•..„, ,„^ _..�:�,,._ ' " 9�(commencing with Section�7000)of Division 3 OF 1IlE BUSi- BIIILD:NGS CJj,2;I, ''cNae�€S"""""'°"^'"""'t"`""^""^""'�-W+ , �nes's ortd ProfesstOns Code,and my li<ense�is in full force and - � � -� � -. _ .... _,,,,..,..�,.,:,,,.._,.,, . ...,.. .ww...._.„p�.,„;,».,�,.,,,��,d„ e�ffect. ` �j � ' � WNiRACTOR�1�kj�t��� CONNECTION CHr}RGE FEE � LicenseNumber 41 $��C C�O55 C'i7,{ . F��RE$5 �22 yJ REIMBURSFMENTiEE � � �~����µ��� �y���� a -- ......�. ,,... ..� . -^4'H- e�^�+•r?. :y� y..t..._. .....=,.,� A T � . „ .: _... . .. � 0 COnhpCtOfm �Rraamaii Dqt@ ��� �,�����g� CRY x��G� .L/D�Qa.•El NO.�� (1 80... D'.STRICT NO. GROUP h1AF"" '`� PROCESSED�BY� V .,.: ':,". .; . ' .., 6K PG ....:... .... , ,...,_ ...:.,:....:.. �.. , � o ,_ ❑ I am e empt onder$ec. of ihe L.A.Co. sC NSE r.o ��4$$7 anss � ._ .. ....,-_ . , � ,� . . , . No OESCRIpTIONOF�WORK.. .. ..,,_kEE•."'•. ....__.._._ . t= 'Plumbng�Codeand/orSee. ' ofihe � � � ,�....,. � . . . . . ..... ........ ....� I�Ol:SE SEWER CONNECTING TO ..._......,.,,»..-..�.,� � OA E� �,following�reason '�- � � � °ueu�'EKea � 1� � p� VALIDATI N . SEMIC TANN SEEGAGE PIT nR -" ^'" GJo vr �B:`8 P Code for the � � �� .-�� D"afe . - . ��. .,... virs nNoiox oaniNFieio = FiNn�� - Z ' . .,�,,,n„�.;,,=.,y ,,,� HOUSE$EWER CONNEC7INC TO ........ _.,....., B� ,n� •':��:' :��._ �c� PRIVATE DISPOSAL SYSTEM ' $19ftp}UI2 CONN"�CT ApplilONAI BLDG.OR "` ' ' " ► ' ''' � ' � � �� � � � �.. . . , . ' ���" ��"� OWNER 8U7LDER DECIARFifION ��V �'' - woar_ro Nouse sewee . ... OVERFLOW SEEPA6E PI?DRAINFIEtD ' "" ""- . I hereby affirm thai I am exempt from the Cont actor's License - ' � exTr�. cessPOOL,Davwett,nnaNHoie . . �QW fOf ihe fO�loWing reasOn($BCtan 7O$1.5,BUISnE3S�nd Pf0-. AITER,REPAIR OR ABANOON HOUSE'� � '-"" .c/� �*�n5 COde): SEwER pR OISFOSAL SVSTEM : ' ' _'`� v��n ... ..._.... R . � `(I,os owner of the property,or my employees wifh wagesas , �,their sole compensotion;will do�he work ond ihe strutture ' '��'''�- t a o o a'� U �.�is_no1 ntended or offered for eole(SecYon.704G,Business - '`and P ofessons Code).. . ..'. �. . . . ' . .. Q�IJNER'$ PeffTllf... � �g 50 �� �'��2�,�1 � ❑I,as owner of the property am excl�sively mntracting�wi(h AUTHORIZATION TOTAL FEE '"' 2� ��.�licensed contractors to cqnsiruct the pro�ject(Section 7�44, I HAVE AT THIS�ATE A CONiRACT W�TH TNE HERFN NAMED CON7RACTOR TC � '� `0 r �,v I j U . 4 BUs�nC55 an(J P o�CSs of15 COde).� CO�NECi THE A30VE�ESCRBE�E%15TING DWEIUNG TO T�7E FUBLIC Sft4E4 ' � � � � � � COfVSTRtYCTIO,N LEi3�WG,4GENCY� � � � '� '��"�-� � � � �� �' ,�2 �� y:h I hereby aff rm�/hat ihere is a construct on lendi,ng ogency � � � SIGNED THIS v F 1�U� 19 86 , for the performance of ihe work for whmh �his„pe mit is � owHeaoe �ssued(Sec 3097.Gv C.). owNeasAceN? � �„�. � � AooaESs Beec woo�t��:�7.�a oma � � lender's Name . .. . . � . . . .. . .._....-_....,.._,.,,-_..�..:._..,.. . .: ..-.� ��-.. . . ; � - . .,� �.:�. ._......_ ....:..... �.�g:,x+ .:,.wx?.z.rs�+..ra�,+y�r�Ft•�,aw,ja ,..�,.a+-<�..r.�K�. . . , . . . ' .._ .. , v,,w�.� dL"H.KiD:� l+�+, Lender'sAddress . . . . ' . � : .. . � ._,. .;.: ..��...G,. >: ... .. . �.. .�.:«,..;........:......e...,�.a-.v-.,.,.,.��.�.e� �_..:.w ... . . � ...:.,. ...,., :.., .,:..... . .,_,-.� _,. ,.._._. �� - �. - ' ..,,.::�... . .�._ � I certify that I hdve ead th�s applica/ion-bnd gtate thal ihe �- � '-. .....,...'�' —..�.�.�.,-� � . . . . . , � . , .. ._... ...._...______ ...... . .... . . . pboye_informat�on s correct,I oqree ro compiy wi�h oll Coun}y -�"�- � � � ���� - ��� ��..• _ ,...... _ .. .. .. � � ordinonces gnd Siate laws�regu�ating Plumbing ond Sewers, � � � � �' ond�hereby out6orize�repiesenlotives of Ihis County to enter ' . � o the abo e entioned properfy for inspecf purpP ses. - SV G�'1�--�-\/1�'I+�>�� �-f/r�I� i '�Signature of Permi(fee � �Dote SEE REVERSE FOR EXPLANATORYLANGUAGE _ _ ________.. _ _. .... . _. _.�_..... _..._---.. .... . ._ _. _... _�,.. , . ... __ �:....:.; ...._s:.. .a:.,.<.�. ..,>,;._. :._��. :.:,::,��.t.� . y�; �� � �r ::._ t� r _, ir�3�croas aucss�s gyX�P�']E�-�TJ�%,�ER 12�CLA[8A'I'iORi . , ��� �. ,�� :.. �r ��.�..�»��.,.�. ,,..�._,_._,:___ ,._� . •. �— /�PPROVALS onr wsa�aox�ssicNnTuae ,..... .dhe:�by�:FYxzas`saxe��a:.zuempt4s�a:uth��.cu4ruceots � . NEW HOUSE SEWER . �.1C4��L8W f09'YL+f:afliaw3r.g xeasor�9.Seeaaem 7e73I.5, t � . .---__�___r_ ' Busd�aesa asuC Y'rofe.cziasu L's�de}:Axy c@iy as cno�n.ty . . . .. .,....:.�..,.� coNN[c�'aoano!va,i � wbscb s°erjrairBs m�ernsi3 io raksRBrsscP a+der, zm ove. ' BUIL�ING OR WORK _ . . . ... . {IEIY60F8YI7.br v��Er x»y sSmr3±�:'As�ar.i4•ss assv�awce. SEG71C TANK,$EEP,%T'S) ' AND/O&URAINF:ELD� � � 6ISD TEk�862A8S &JJP pi�'Jo�7C2tyY�'3f 376CJF pE3'YN9££G jiZC 6 ?' cessvooi❑ oarwEu p ! . . . sri�ne�sradev�sse�8 sRirsB l.w is I�re�.a•ad g.�rsseuaa¢So ibe e " Y� proasrions af zbe Co+ec"rsrlus^"s Zdcerue 7<rnnta��CS(sp78er 9 3p . �:� FLffR.REPAIk,SfWER DR :......_ .. � ...... . . ... `tODitAZ3tlCl9{g':'J63I5 S¢CPfo#i���O��LUfSfOA�u�$NC ' SEWAGE�ISPOSAt SYSTEM �� .. �ISGONNECT PLIiG IWD +��b'Y�°�'���'��e4SY6Y➢,1 C4i�Ei 6p i�ME�2,33 PYefH�d ABAN�ON HOUSE SEYVER ........ 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