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HomeMy WebLinkAbout1569A � '�� '�'�� .f,.;;,..o,:,.�rw< �,.._;; ..,,.�s:.T,.�'� '"���.�n:�lie;�nse.sw:u.;,;w�e+..,�_.,,....... �.. � .:. . �. . _ ... . . . . - `w�'+..-.^.°. .. . . . . . . � � . . . ,-y.� . _ ,V„�N.�Z(�Fj2rS, CO_MPE.N,SATION DE0.AR4TION, . ' . . . . . . � � I here6y offgm,�ha� 1,�ic�v.�,a certifiqote.of consem to self � nsu e,,or a,c�.�)Af cpte of Wockers Compensation Ir,suran[e,or �°A°^1� /�pp /�T w, T �o�cert�' reof(Sec.3800,1gb:.�Fund �Sce�aev.�a�ei� .Mf-i����./"�f„�ol� „FV���.,1VY4!1 ,�:,: .. �,�, �� � . Pol cy Company �b . . , �. � �i Cenified co�is hereby f�ys�ed,H:.s-nx .s:°• � ,.•,..• . .`,e: . -� x � ..�!w �,+w:.,+.�.�.�,��.. �EW�6,� DI�POSAL ',:,, . �� ...., , g „ P _ ,_, ., �Q�NTX OF Lg5 ANGELES BUtiDJNG AND SAFETY �]Certified copy is filed.with the county bu id n ns edion _ . dePariment .r .. .'__ . .� . . .,.......,...... ..., _._E' . . :"� . :...�.. , . 8 20 86n ��a�� T. Freeman _ ,�' ._ Date � � . P�.,. ., FQRTyAPPLICANT TO FlLL tN �� CONNECTION DATA CERTIFICA�QF,�X,EhJPTION FRQM WORKERS' eur.oiN�"'" � " ' '����'� �� �' "'� `���� ��-�'�� ���� �� . .�:. �. .�:'�`����,"w,P���CpMPENSATION INSURANCE nooaess � . - sTancn oevrH � _. _,. � .... _. .. ....... . .. ... ..... .. ,..�� .. .. (7has.secrion need not be compl,eted if.tF12 w0[IC IIIVO�VECI bY ff1E ;p�ALIiY .l!MNHOLE REFEFENCE - - . .4PPER � . . permi�is{or one hundred dollors($100)or less.l ... , . �owers . . nlEqr'tESt ' '- ` � ^f?EOFCONNECtiOh � '� �� IENGiHFROM I cer�ify thot in the pe�Joqnance,of.the work.for which this ceosss* �3 v cuae a.i. r�a.i roPi . ' permit is is5ued,I shall not employ any person in any manner ,-...�....��..�.�1T�.:.1�_� (.,_1'p�. 7,� ...-. .. � . . . _ .,... . .- �� .. FS1YtJr•'� VA1S '� V,C NC. . so as to 6emme subjecl to the Worken'Compenso�ion Laws. pwnea co.ifna.No �os n�o. a1 . „ .. .. .,.. . _. , . .. . . '�I` 2 iRUN�C_PERMIT.I�.. .._._. .... .ROAO PERMIT NO. � Dofe Appl cant, noo�s5 . . - . � .. , - - :�:: ........ ... . . :.,.,..:, :,. . .N .,. . .. . NQTICE.TO APPLICANT� If, after mpking fhiS Certificare Of ��J� AFFI�AVIT WAIVER EASEMEM RECORD.INSTR.NO. DAiE . ��� �mpuon, yo�.,shoufd .become sobjact_tq_.Ihe.Workers' �a��.�a. TE�.�. 818 967� 41 : . _..,.. _ ipensation pro.yjsi�s_of,thg Lobor code,you must forthwith r�sCk aiioN iot Na � � ' . ,.. .... .. . .�:. ... `t-s�hply with such provisions or this permit shall be.deemed � •«�� � ����-..-� . Hwv.oRsr.wioeNiN� . rCVOkCC�. Bl6Ck TRACT S�P.SE�NCROACHMENT � �����' ����� � ''� . �:.:..�.:��..�_. ........... :.»..... . ,iW.OF B:WS. PEkMIT NO. � . ,r,wL,�,C�,NS,EQCONTRAC10R5 DECLARATION szeo=tor - � �� ' rvowOn�Ot ' '� " "' "�'�"�-'�� � � �, ._.,..,.,...._ . I hereby qff r,m,ibal I qm licensed under provisions of Chapter u5e �"� ` ""�" "`' ��" � ���� � 9(commencing with Secfion 7000)of.Divisivn 3.of the Busi- eu,��ines � � ����� �.- � �.. �....�...�......"CHARGES .. . ..nesspnd Professions Code,ond my litense is in full force and -.-,. ...M- .�..t�y�g� * �y�'�T�rm-��- �- � � -.+ +,--� . - •-•�•»•--� -- �- �� - ' � ��. effeCi. f,ONTRACTOR ,1;�.ti�ra1�1YT WO1Yr„J L• CONhECiION CHARGE FEE � ' AQ�'$�/ .�».c. -.. ..,--.. ......,.. .._.,.,,.. ,. ...... . LicenseNumber ��Y`"`�1 I.0 C�g$5 ��� AUDRE55 � - . . .� �ta'(� REIM9URSEMEMFEE @ .....:.-.r�.,�•w��....�..e.,......., ...-'a--��+rt.�....� / . .Co��t� II1831 Date SI2O/80 �~ DISTRICTNO. GROUo MAv GROCESSEDBY V ' ...���...�.,-_.��� .� a. TE�.No.714/980-4429 3K � z . ��-YAlta T,om ❑I am exempt under Sec. of the L.A.Co. �i4�E�„� � 8a � cLaSS Z� o � U NO. .9t"SCRIPTION OF WORK "��'�� ��FEE � Plumbing Code,and:or 5ec. of the � - . :INA� � _.. niwsEseweRcoNhEcnNc,o ], �p ecre �l�Z� ..d� VALIDA ION d auguc sewE? . _B„8 P.Code for the foilowing reoson sePiiC rANK,sEEvacE alT CR � � Z '. v�iTS AND'C�R URAiNF�ELD FlM1AI � Date Bv �� . . .: , .; . .. �. ...,.. ,. . IqUSE SE)YE6 CCNNKTING TO ,. � , , ". .� . . .�.. . ,.� � �R�V.4tEDI5PO5AlSY5TEM � �.r $�n�OtUre iOYtiECT 4DDI'�QNq4 9iJG.OR "` ��� " ��' . -'�'�'��'� �._OkY,.�IER-BU,ILDER DECLARATION woaK Te Ho�s�s�wca � � I hereb affirm that I am exem t f om t oveuF�ow seeva�e aiT,oeaiNFieio � � . ��. y p L ...h.�,ConiCOctor'S License ExiN..CESSOOCI DRYWEIL.MANHaLE ., � .:, . �'-. .� '.::. ,,.. .�ow f,or th,e following reason(Sedon 7031.5,B�isness ond Pro- utEa,aecqie ae qervvppN Mo�56 � �� � � �" '� �' � � '� , � �(j C F� � � ' � 'iOns CoCJ@�: SEWER OR Di5PO5AL5Y5iEM . . • ... . ...... ... . - _.!� -.,�,I,os owner of rhe property,or my employees with woges as , H°� '� •' I C � � their sole compensotion,,,wjljs�q.the w,ork and the struc�ure � �� ������ -� �� �� � � - . � � . __ „__,,,jg,17o!„iy�fendefl�or offGred for sale(Sec�ion 7044,�usiness � - �� L,J J�{; �. ,and Professions Code). OWHIER'S PCrmit 5 1 Q � . � . -' . , ' .- ' . . ' �. ❑ I,os owner of the propery,pm exclusively wmrocting with AUTHORIZATION �TOTAL FEE `Z 5Q � r� .�'c'!.7�:j c -� �' � . . .. .. . ........ ...... ...,... .. ,.. . .. ,,,�e�ys,@�cRDf.44F3R�s,_fo,construc7 ihe projed($ecfion 7044, '-" � � �' . �- � . - ��� .--,,...+, . .�M�+�E Ai i1+.;5 DAiE A CONTRA�T WITH THE,HEREIN,.NAMEO CONtRACrOR TO . . ^ /� ���, .,.�,. �_ ��V;iq255 dnC�ProfESSIOnS COde}. :ONNEC ih[,ABOVE DESCRIdED E%iSi1NG D1ME::ING.iQ TNE PVBLIC SEWER, � ?[.�y'"(j U {� ._C.OJV$JRUCiION LENDING AGENCY � _, � , � � � .. '.'". . „`-�-M_ �� �SIGNED THIS ��_D Y F = 19 '� . ,. . .. . I hereby afficm ihat there,js,q construction lendir.g agency P � , - , � � - �� for ihe p,��,yyap,� o�,.?ne.work for which ihis permit is OWNEROR 4 � ' � �. iSSued($eC.$097,Clv C�. �WNERSAGENi �'��� ,n . .Lender's Name nocRess �c-e3� -' yt��,t,[+.�'! '��� . . � �M�...., ... „. . ..�.�� :<.:.,.,, _ ._,�.__ �,..,...,.., ....... , --.c� -...,. r ,...�:: . . ,. ;�. , . . „._.. ,, . Lender's Address � ...�. ..; . . , • .. , . .I '.���. . ' � ....., . .��. . . . ..e,. . ..��_ -.. . . _ . .:. . :,: , -� � I certifv thai.�l�ave read�thi's'aPPlseotig�pfad_s�afe..7hat)he � ..:� �' ' � � � �`' � � , . , abov�iqior,mation is corteci.I agree lo comply wiih oll County � � "� " � `� � � ��� �� . � ' - �, ,. ord.nances.,and Sta�e laws regulating Plumbing and Se.wers, . . � " .:�'': �."��,��� ' ' �%� .����� � " � � . � and hereby authorize reprQsentafwes of ihis County to eglei ."' ' ' `� '� � �'- ���"�`� ''-� "" `� '- ' � � ' the abov�``�e�ntioned property for inspe�ctio pu�p ses - < �� � � ' \ L �`C�fl$0�1'��6L `''��(c��,_ . . Signature of Perm nee Date � H.�>o�,,��� [.�.. cc�,�:�� QJt�,�lWG4AGE _ � � .. . •���. '.�� .c.'�.;.. .�'......T .ryn.n,v �`g�5'�'h�''r�'. .,-" _ ., .....:.�. .'.:.:....�'-` . . . ' ' ::: � .. , ,'.. ... . . � .. ' ._ . ... . . . . '� .. . . . . . � . � , , � .. ,., ;„ . :. _ . ,._ � -.. ,. :. . q ,. � t:�{� �:,' . , �__ , � 7,;.�- . 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