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HomeMy WebLinkAbout1556A . _. _ . , . , . . .,: ,>.�,. . . , , � , . . �_ . _.. WORKERS'COMPENSATION D,ECLARATION,,,, � ..... ...... . .... . ..... ..... _., ...... I hereby affirm ihat�I have o certificp(e of tonsent to self ��� � ���� �� � -�� � -�� --- � ' � ,' .... .. ..... ....�6A6n2D ' . , . � , insure;�or d certificqte of Worke{s;Compensat on Insurance,ar � � � ocerffied � r f(Sec.��380G,1L:6G.1_nd CE�OB�REV.B%BI� APPLO����ON� FOR. PERA�IIIT bT i'IA , ,PoLcy No Company Os , SEWER - SEWAGE DISPflSAL - ❑Certifie co y is ereby furnished. . �ce�tified copy�s filed with the county buildinc�inspection COUNTY OF LOS_ANGELES BUILDING AND,SAFETY _ ,.... ._. -�: � :�dePan e� . .. . � .. �f�20/�6. T. Freeman _.__. ._...., .. Doi,e ppiicom POR APPLICANT TO FILL IN CONNEC710N DATA .� . �� ��� CERTIFIC,"AtEOFE�'Elxv1,PTIONF,RAO.vNfWORKER$�� � � � � gw�D!NG �() � ��-��� � ' �'�-����""��""" ��"��"'�"� � . COMPENS�IIaN�NSUrtf��CE� � � ' ADDRE55 p�-�{ � � � STATION D�pTH �'. . :�.: ..�._�.. � . ..��....... ..�.. (This seci on need�not be eompleied f'iFe wo k ��vol�ved by�the � r.wNHoie xEFeaeNce � ������ � �� " � � uP�R - n IOCALIiV �' permif is fo one hundred dollors($100)or less) ,. . ���'^'ER .._._.,_ . _„...._,..r-.. '� � � � NEAREST � �-� � � � ����� �� TYPE OF CONNECTION � IENGTH FRbM' -�� i-cert�fy �haf�in the pe formonce of rhe wo�k,.for�which thig caosssc - . r CURB v.� M.�Toa.i, - permit is issued,I shall not employ any person in ony manner � � - �..... ....,. „..................„.„. _. . . __. „ � �ac,No. ' � `�".. .�.... ,.. so as to become subject io the Workers'Compensafion Laws. pyyNER N � � �p.�Mp.Np. �oB No. a ✓Ju ; ... ;:�- :^:=;. . , - ' .. .. . . .. . . � NWIL (�. . . . . . . .., , . .. � � � �� ADDNF55 PO B�(����Z� TRl1NKPERMIT�O. ROADFERMITNO �� Date Appliconf � � � '� � -- ��- -"�-� ' � " � ��� � � � '�� AFFIDAVIT 4VAIVER EASEMENT RECORD.INSTR.M1q �ATE . _ _ ...��. _...,. .�� NOl'ICE"��YO APPLI�ANY:�Yf,afier making,ths Certificafe of � �itv �1a,�S8, Loma�.No. a1g/a67 954i �� � mplion, yo�� should�become sub�ect ta ihe Workers' , iE�A� � � � ; - � - � '- ' �p�ns6lion provisions of�he Labor mde,yo�musf forihwith oesCaipriCN - LOiNO. � -� ��-� - -��-" "'"".`..'.",.,"". . . .mply with such provisians or this permit shalf be deemed A Hw'r oaST.wi�eNiNr, _ .. . ,_ ._ . ...... �EVOkCCI. � B:OCK TRACT ����Y� STATEEhCROACHMENT � '� �� � .. .�-. �.. .,: . ,. .. . . .. . .. .. �.� LICENSED CONTRAC70RS D�CLARATION'� rvo.oF eioGS , ..._. .,-, . . ...... ..,, size oF�o, Now oN tot . ....... � I hereby affirm t�aP-f om I censed un�er provrs�ons,of�YChapter use oF '-" "� """"�"-""`"���' �'� � ""� with Section 7000 of Drvision 3 of ihe 8usi- aw�oin�s SlI1 ZE �281CZE311Ce �--...�.. . . .:.... ... 9 (commencing } , g . . -CFiFiRGE3 ��; ness'a'nd P ofess ons,Code,and my license is in full farce and �� � ��� � ��- �� - � ��� � .�— -��-�..--. eFfeci: � , . coN.ancroa j�'j'��+'L'''�1��`7 (�`,��ruT. Y , . ,•Y _,:,,.. ..�V,L..� N} CONNECTIONCNARGEFEE L cense M1f m6er 4�L�8$`7 L c C�ass �i�1� � . ...... ..... ...... _...,. _.. .____' ' p_ ._...._._......._.............. . , o��o���,. „ Fl�DRESS „ ' REIMBURSEMEMFEE � � Contractor Ta ��I'20II13�te � �ry} �^ �} O /� r� DISiRICTM1q GROUP MAP VROCESSEDBV V _,..; .,w,. ...... :...,. fITY Xi.VaryAJ.1o1�Q71� iEL.NO. /l� J�VA�'��G� 9K PG z � ❑i am e empY under5et ,,,�� of the C.A Co. SCENSE Na. 4'f't88 t c nss�3`1' �(} � .. . � . .". . �..� . �:-' ' • . . : YO DESCRIPTIONOFWORK� ....... ...FEE':.�... .-,... ...•.. • �� Plum6ing Code and/or Sec� � � ���� ��'� of(he � . . . , FiNq: � c"�auc siwiR mNnecnNc r 'T OO rE (/�� A ION a 'B.�B,P CO[IB�O/��{lE fOIIoWi»(J Iep50f1 � SEPiICTANK.SEEGAGE?ITORO � - """-' "- '- y � �A : ..�. ."; �..-'. ... .:... .. FITS ANDiOR DRAINFIELD.. . .... "IN A� -$b � ' . . ISate � _�� MCUSE SEwER CONNEC7ING TO � - � - ' BY I ' PRIVA'E�ISPOSAI$VSTE F � . $i9natul'e . . � �-� ^� ' CONNECTADDITIOhAIBIDG.OR - ... ' .� � ..,,6 r{ " ��� - � ��OMNEf2 BUICDER DECLAT2ATION "' - � ' woaK ro Ho�se sewea � ^VERF,OW$EEvqGE GIT,DRAINFIELD , I hereby otfirm that I om ezempt from the�Coniroctoi s Litense ��,-� [xrn,.,cFssaoo�.oRvwEu,nnaNHote , 4;< '� ° '- I 1J Law for)he following reason(Secion 7031.5,BUiSlle55 OnCI Pfo- ALTER,REPAIR OR ABANDON HOUSE"' -`"" """"''-"' ' ' �€�*'`"W,�ons Cocl@�: � SEWER OR OISPOSAL SYSiEM , � �,_ f G 1..�.iJ . � I,as owner of the properry,or my employees with wages as � iheir sole campensation,will do the work and the strucNre . � ��-� "c' °r���%�i c - ��is�not intended or offered for sale.(Section 7044,Business � ���6nd Professions Code). -� '�" � ' - OWNER'S Permit 5 t'J i3.�9"-�u . �.C I,as owner of the property,om exdusivaly contraUing with AUTHORIZATION TOTAL FEE � � . �. ��licensed coniracfors fo construct ihe projecl($yCti011 7�44, I H/+`JE AT THIS DATE A CONT4ACT K'ITH THE NEREIN NAMED iVN?ftACiOR ip , � ;�,BusinesspndPrafessionsCOf�f�. CCNNECTTHEABOVEDESCRI9EDE%ISTINGOWELtING�TO'TFE7l'1BLICSEWER""' ' -' •� CON5TRUC71bN CENDING AGENCY ��" � - , I hereby ffi �.1h6t fhee 5 a consfuction lending agency � SIGNEOTHIS D YOF -�'u�����, � 79 $6 for the pe fa mance f the wo k f r which this permit is °WNER oR � issued(Sec 3097 Civ C) owNEesnGcN� p n(C ����..�� A,y - . ...., AD9RE55 V GJ eechwaod I7r�• �1'1�.4GZ. Qma Lender's Name.' . �:... . . . . . .: . . ..........�.,. ...,.............._..,......_.,.,... .. . . . . , . ...... ..,.. ,.. , . . -, . � .. . .. ._ ... ...;., . . . , � . . ._� , . . , . ... . - .. . ': : ...: �- ,:., ..:":�. �'���i'�t � : . .. . . Lender's Add ess . -.. . � . .. �. . �. .�' , . .. . . " ' . � � . .`... _. . _.. . .. . . . . . . ... � ... ..... . .... .... . , � '� I certify��that I Ii6Je��read fhis oppf�at�olr a d�sfdte��ihat ihe ' � �� ' � � - - � �� �- � . . .. ... . . .... ... . . . .. ... , � aboye information is correcf.I ag to comply with all Counry � � � " � ordinances and Staje Ipws regulating Alumbing ond Sewers, . and hereby authorize rep�esentatives of this County to enter. � � - � u '"ntjhe a6ovqme�ntioned properfy for inspe[t' pur ses. � P � �nGa�� � � . � �,.Signoture of Perminee ��Dote.� � SEE REVERSE FOR EXPLANA70RY LANGUAGE . . _ __ _ ; �Y.� , ;;s > , a: a�sr�nre��s�or� - ��t ��� � nr .___ ._. ,.._. _ .._ .., . „�P.. �]l�d,��1R �i�T"�L?. ...._ �.,.._ . . _. e. ,_;., , A�PROV�LS � DAYE INSi:CiOR551GNATURE _.I�fl2fEFi�AEFl2'ui't�1�E8T�D3E%v3SijYt�XG§LCIYCL:ileIY28CY0[°ft �. � Nnv sause sEvu�a — ,.��_ Licease i.aw f;s chi�alTowiug reawn(S�:ason 70�S.S, � .'.:.. coNNEcrnooir�onwi : . . � ... ..._ $sesinaas ra»d�fessoars Cadef Assy zdg� or c»sr�d�� .,urbicb.�rzgrssr�x a�rs�t sa.,carsc#�cr,c,a>3sr,sszsprooe, " BUIIDING OR WOR% :,.lX8HFOJASI3�3Y)'�f�i'3W si%SSSi&'1'8.�9'fiDP�585 FSSM�"�:¢CBr �� $EPTIC YANK,SEEP,PIT(5) - � y �,'.5 M ._-.. AN�/OR DRAINFIEID __ . Q�Jo 9'Ce�l�.'SJ85 L3h�A11,f1PtCA%l�50Y SCi:�J p"YE4'ri"i9t d6 j�ElO a . . . eessroo�❑ �a�tivei!p 1 . . , signaid'x�8a3¢ar.�sst ta3a�,�s?fc¢sta�e�'pe�rsrsavsf to Chs '. AL7ER,REPAIR,SEWER OR _—��_— �v�e�"���e�+�tri3CAbY'0Y LrCeRs.4:..¢Ell(CIM�EBP J ..�S.EWA�E DISPOSAL SVSTER` .._,_ . . �COfiYYbdL'7dt'iP1�,3i/edFi'.Fe3Cd�809A i6Ci0)<af YJisrisdon 3 af th� ai �.' �oISCCNNEC7 iLUG AND - � Btts'.t36&S asr��''rufesai� �e.�lej ar ebai�$e wc aa�mpe . . e aeawooN Hous�sEuveq � . .. ......... tb�r•efrom axd vbe zirs.sis?ar-ywe a;lega�axema�s:ovi.Any .. aacKau�aric rawKs❑ . vio8atdosz af.Fes3rar.i 031.5 d�y�»,y�ppdsrdsss,{oar updrmit �.'.....s�v,wYrs}❑ cessvoots G . . �. '' •� ....._... sae8pects�ne m�h 15ra�&�±rs a zltnd�rsntaJfy ofs+o�rrevre zhan . .....'. , . . ,.. . ....,. .. .� . . . _. . . . - . ,: , . , _ .'-,`i '',� :J:�. - ,/"svr�e hmudred dodtaas�$3titAJ: � , -,:- �, - :. �:,..- ,,. :, , . .: �� . : � . . ...... . - . E,as th�o�ser ref slta pt�pe��i€�rlc+the mark,x • : i . the sffi:icturz is nne iutended or o3fered foe vafle, . . _ ,,. .. � ., .. . . �. . _ . ._. � .. ... .' .. � :_: . . . -.� ..; -. .. ',:..'::..�. �Sec. 7�4�, .$r.siaeu�sd Pcr�fs>sions Cnde:�'��-^�w ' .j° . .,. . , , � . '., . . - .� . . . . `�. . . �. ..-:� ,.:, 'lrnctor's S.icsnse'.'�;a�o`doas:�at ra$�l'y 8c sot oE of ' �.. ... ... . . ....... ... _.. - -- - � � . . „ . . , .,_: � t,�,a�.'-._ . .....�:..., peropsrYy avho Laootda oa imprae,er abeweoaz,ttwd wba dnex ; � .�,�..... .. ......... .. ..... ,__ .. . .�. . , - �� � � ' � �G snth wa�rk diin�zrsif yr,or.�irded 3lmC susb mispra�emsxiss , . , � . . are�s�o't�4vae�ded ar�0P¢tZ,�CP Se3�B.�r'�arz�uar, tbe � �...._ _ . ... -_. .._. _., ... . . . :, � - . , �� ,, ysx�r�¢of .-�. ...�... .. . :. )�_ ' . ' : ,-',� bra@ldisa��r��roriexsesae is mld.vitbsr. r,ne , .t. �, �.....�,. . .._. . _ .. . ... .. � .. .'..�� - . . .. - . ..... _ .. '8etfon �° - bt�ei - Zf�io t0ie � _ �... : -� _.�...._ crsnap . . ..wxier� Jd¢F ,ui e -� _, . _ . �� � F . , of provixi�tbas he,�ed.zmt�isee�d uF•dreaproz�e¢or sdas n ....... - ? ;..... .,.....-- .,.._ _.._ . �' .;.' .'_"! ' .., - -. . ` ' . . . urposs n.w . ;,i..:-., •, , r t i ;;Sa i !'I$flY eYL`e�pt;u�xCIe$.S�Ce�:;,_,a__,_�: : �;., _ ;'`. ::,��`;a _: _.:... �ox rl�is se��an : _: _:.... . $8��.C. , , , _ ::; : ;.��,_, +. : . . ...... ... . ......... . . __.. .., .. . ... . ,.. ,.. : � _ _ __ -.- ?, t3ate _ , , _. _ — -._ ._ ..__ _.. _. , -... _... �_._ _...__._. ... _ ._ _. • ° �aun� , .. 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