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HomeMy WebLinkAbout1557A WORKERS'COMPENSATION OECLARATION I hereby affirm thai 1 have a ceitrf�cate�of consent.to seif, � � � � � ., � � � nsure,or a certif�cate of Workers'Compensorion Insurante,or 7sn6a2D- .. . .. . . . . ... ... . .. . .. .. .. . . . a�e"'� o eof cse�:'8°°;`ab�. ``Bob`R`�e,e�; APPLlCAT�O�V FOR PERNIrt � Pol cy Companyst• �L�C� Js , SEWER • SEWA��E-�SrSPOSA�`_ ..,_.. . ....��, _.. _.__.... '�,�Ceriifie copy is here6y furnished. � �Certified copy is fled wlth�he counry b�lld�ng inspectlon COUNTY O,f,L05 ANGELE$ BUIL�ING AND SAFETY, ' ' ' - depariment. . � � Ddie ' ' ` 'Applicani " FOR APPLICANT TO FILL IN CONNECTION DATA _ ,. . _..., � '�,: �� CERTIFICATE�bP EXEMPTION FROM VJORKER$'. . . � suuoir�c ,t sTnTiON DEVThi � ��," °'.", - � �OMPENSATION INSURANCE ���� A�oaess �- L. ry'1(o C � �'(This section need not be completed iflhe work involved by the D����D �� � ��� � ,m4NHciE REFEREN[E uPPER .00ALITY IOWER permit�is�for one hundred dollars($100J or less.) N�nREs� ` � , TrveoFConNecrior.i � ��NGiH FkOM - ��� � � ��-I�ce trfy thai in the�performance of�rhe��work for�which this cRoss st �r� r v. cuaa a.�. ^n.i.*o c�. � �p�rmit is issued,I sholl no1 employ any person in ony mpnner � ' � �:'"so as to�become sub�ect to the Workers'Com ensotion�Laws. -- � r� v.c.No � � P OWNER CU IMP.NO. .OB NO. � '��x/,'� '/i(,.�.,., l �. 1¢� . .'.: .'�. . .. , NJill DQ1E ��^`��""'��FJI Cqfll a ADDRE55 � TRUNK PERMIT NO. 20A�PERMIT NO. ���N�7�CE�YO A�a�i°tni.ir �{ a{�ef ma�(InJ this��Certificate of ��T� AFFIDAVIT WA%VER EASEMENT RECORD.INSTR.NO DATE ,::�,mption, 'you'should bemme subjecY ro the Workers' �+OV1Z12. TEi.NQ�1$ � .r �� ensarion rovisions of the Labor code, ou most fo�thwith oescR vt�ion iorno. P P Y HWV.OR ST'NIDEN!hG ,iply wiih such provisions or ihis permit s'hpll be deemed "YevOVee[J. BLOCK 'RACi STATE ENCROACHMENT "..:LI�EN5ED��C`ONTRACTO{�S DECLbhATIO1Y'� No o�BLDGS. PERMIT NO. ' �' SIZE OF tOT NOW ON lOT '� I here6y�affirm thai I`am licensed under provisions of CFiapter uSEOF � � � � .�9�(commencing wirh Section 7000)of Division 3 of the Busi- euaoiN�s�'1 1.@ R@S1C�.QI'1C@ cr+neces '"'"ness`and Professions Code,and my license is in full force and p� �T � � �' effeCt. +� p v� A CONiRACTOR� ��j+�HN COlY CONNECTION CHARGE FEE r License Number �f�GJ�f �IC.��055 �3`k AD�RESS ��� Beechw ��d REIMBURSEMENT FEE o . .. . .: .^,...',..� . ..:p e� p � �� Contracf,or � Fre�ma�}.Date O'G�/[]� y. DISTRIRNO. GROUF MAG PROCESSEDBY V . , . ... C:'Y � y`d, . TEL.Iv`O. � eK FG j„� Z �� � . ❑ I am,ezempt under Sec , �of the L.A.Co. �aivse No.. q-748S�I cinss (' � V � o �� � ' ' ' � � NO �^ESC2IPTIDNOF�WORK � � FEE � � ~ u . PlumbingCodeand/o Sec. - ofthe � - ��hA� V/�LID�4TION W . �� '- - ' �-- pOUSE SEWER CONNECTinG t0 .y �AiE � UeuC SEWER I p QO �Z.���.. � � 8 &P.Code for i!ie following reason, seatic Tnn�K seevn�e�r oe � � -� � F;�,q� � z ..'.� ..� ,�. . . � ', � .�-�� -,•:...�" P!TSANp/ORDFAINfIELp. . . . � �pfB HOUSE$EWER CONNECTI4G TO '� 6� '' �- ' ' �' PR�.VATE C,S�OSAL SYST $IcJna�u e CONNfC1 ADDITIOh'Al6��G.OR , ' � '�--' 'OWNER=6UILDER DECLARATION� ' � �� woaK*o House ser�e � I hereby aff rm that�I 6m�exempf from the Contractor's License� ""'� �iirniF��EssPooiGoa�wEiRAMaNHoie Low�for the following reason(Secton 7031:5;Buisness and Pro- a�rea,aeanie ox nanNooN ryouse - ., - .,.,::�;onsrCode): sea�eaoa�o:sxzsusvsreM � — f �..;.. (R � I,�as'owner of the property,or my employees with wages as ., y•, '• 1G . � their�sole compensation,will do the work and the structure ,� . , is�no1 intended or offered for sole(Section 70d4,Business � m a;�;�_.�'} �.'and�Profession's CodeL � OWNER'S Pe[miT S l� � ❑�I,as owner of the properry,om azclusive�y contmcting with AUTHORIZATIDN T�TAL FEE `Z - �� r�,:`'t)� � I�censed coniractors to conslruct the projed(Seclion 7044; � i Have n�rHis onTe a wHTencT win-i rHe Heae!N Nnv,eo co�ten[roa ro ' Bu5ine55 Ond Professlons CodeJ. CONNECT THE ABOVE DESCRIBED EXISTING DWELLI4G TO TH�i1C SEwER ' _%t��.-�� � �'' Ct>NSiRUCTION�LENDING AGENCV � � L , � I hereby�aff m tliat�"there �Is d�mnstruction lending agenty � siGNeoiHiS vOF Aug_y._iv 8V - for ihe performance of the work for which this permif `s " ewNEe oa p��T�� ssued(Sec 3097,Civ.C). owveBsnc=rve r1�]�+ yi �T„ n�y � �: ,.'.�,. ' :,��..:. . , ',,- -.. .: ' �, .:.,...� . . A�DRE55 �L G l i3oechwood Ll".� tu lia. Dma. - � Lender's Name.... ... . :.'; ' .'...':." .. . � .'........ . ..,.,���' �:,.��-.,:...'. .. . ':..:i:.,.. ..� ',. „w...........».,� ,._.._: ...>.......... . . . . ... .. .......... ...... .....�.. .. ....._._. .. .._.. .... . .. .:__.Lender s�Address� . . _.... ....... . .... .......... .. .......... . .....�....,-- .,.,..._.._ . ....... .._ ..., . . ..._..,......... ... ... .. ...... . ........ ...... ... .. . ., .. ._ ... . . . . . .. .. ., �� �,� � certify 1}�at I have read fhls appLm±ion and state thot ihe . . above informotion is correct I agree to comply with all County ���ordinances and Sfafe low;regulolinq Plum6ing and Sewers, .�.��dnd�hereby authori¢e�representatives of this�County to enter , � ,� - � � � iFie above tioned property for inspection�purp ses. � ��;7 NI �t.!I 0 e 13�4'aCi� ���f7 .. .-3 g ature of Permilfee Date SEE REVERSE FOR EXPLdNATORY�LANGUAGE � . . —�4., � . . . .�..,.�..w...................«,,.,,,.�..�,—m._.»�.-..,..-P....,a„�.� .. ,�--•--q..,...- ;t at�, � .;: �� ,�,; � .= F �. tNs��ctoR's wo� o,�ia-&i1JIx.1]�lY 831Ec��.Tad11W +..� r��, * � .. , . �....� . .. ,. ,� .�PROb�ACS onre IIVSPECTORS SIGNATl1RE T here�q�af�ix�a,tSFax Y s�esaangt�n�.ihx C�ntu.�.or'x � . NHMHOUSE SEWER . � �.IICkRBC A.flW fOS Y�Z fO�IOGVSiI�tC850A g,SBG`SP478 703i.5, CONNECT ADDITIONAL � "' BHS£#BSS AbtlGl PTO,f85�9td C06L8�`LY93y' CrL^y' OP SbPttSLjr eunoiN�oo woaK � . wbicb aeqei-��es a permit ta comaxruct,atYer,isaaprova, �BroiO/a5/i,c7 s�6gSRia'kxy 58tYICSuve;,�anor Ea i£a f.ssa`afe�e, � AND/ORDRP.INFE�LDT�S) ' 6ISU !¢quIPB3 BFl¢6�I�FiC6T3#�r,r sitCb pe3'fHr.S ta fBre B e'3H - - sigtted atataraent aha5.$e zs dacesuer�pearsuane ao tbe cessaoo:❑ aR�(w€u❑ . . . , .. � � �rovisions af tlie�amRrccEors�Ltce+ue Lscfv(Chaptar 9 ��f� ALSER,REPAIR,SEWfk OR - ' ' � ' '' }�COfNidtBfbC8A8'BUtCTi.SBC#801d ]�d�j b,j�19x1iEs0➢8�o�t�le �,`.. SEWAGE DISPOSAL SYSTEM : . .. . ' "- :..., Business s»sl�Arofa.csioma C�af�r Ebat be is exetxfrR �f pSCONNECT PIUG AND �k� ABANDON HOUSE SEWER _ —.�.— . . C�¢P¢�YOTA G'%[x Sjl¢�IQSYS�Oi'$IJB AY6¢g¢G;¢S¢eYd�l28ofe.AN,t fl4CKFILI SEPTIC TANKS� . PJafR8t09Y 0��8tEYUYi 7zJ97.S bj'4Sfl',��1'�y3C6%E,fOT[G iifl9TJt$ �'{ SEEP,PIT 5 ❑ cessPoots C � � sub eetc 3be [sca�:sn ra ciuil ereal' o nnE rranra thavt t, t i i �P` g $3 f ... , ,.,. . , ,:,r+� - �;:; ��bmmdred doe;k�'s(�300/.: 3 .. ,::? :. � t_ �.,:r. � . ,., . . . .,..... ._.. _ :,,.._:. .:._.,.,. .;. . ,.. . ._.__., -_- ....--_ . .- , �.'..� � Y,as rme mwnner'erY 2�xe proy;eP.;�rvsle�Ao[tse esark,acui � � � _ --.L 5�t.-_ ':'� . .�.-:= . :�:"� l"�:':'�'. � xhe attucLure is not iaYen3ed�sr affered for sade . .. . . ; ,• _.._ .-. '. _ : , _....; (Sec.7044,Hsrsitaess ated Prajessi�ias Code T�'�.:Kz- ; . ' . .. .. ` aracto'r's Leies�se�i does Raa�Py to stn.a. of „ . �._ ,. ,_._.. � . .. .. . .�. ., .-.,�:�. .... _ _..._.._ .. . .. _.. . .. ..— - . ._ .. ._.. . .... � � � . �� � ��,... . . . e �� �-� - >• .... . �roper�Equihv buif�s or impi�vex therson.�and wbo rZoes � ..::� . . . . . ,�. � .. ..::,, .._ _ . .. ._ . ..:,..,.� �..,.. .... ..... . . ...:. seteb wark bisntelf p�uriided��Chat sss'cb�itnprccivssnsads . are sioi iateaded or offere�jor saCe.Z},howsv�er, t5e �r- . ... .._.. .� ... . . _ . ... . ..... ... ', ._....,� � , �. . .. buildf-ng�hs^�inaptnvemans as s�Id avi6hdra ome ear af ."r.. . ... . ..... .. ..-�__... . .. : . ., �, � ..:�- _-.,_.-. � _�._, .;^ r.�• .� ;._.': � � bave Sbe 8urd'ers com+�letiott, ibe oumervbr�dldrsr utifd .. . ..�. . . . 't.-y.�: -..:t.,;: .:"..� _ .. .. . . of Pa'nuisg abat&a dsd noa 3suSld ar mpv»»ve for Yba �,.... .._ ... ., . .. . . ....... . .. i' , .Eua F�r t*,."� t. _,, , r . . . , � . , , , .., .., ., .._. .... _. - �uspose.of sale.) t , „ ... ,' i _ , , � ... ,. ..: . ., __ . . . ,.S.� , . �aa�'exesmgt�ader��_ _ . � . • • �r�=� r B�c�T.C.�oa:3sis reason _. .. _ _. .. . _ _..... --- ,: ,,_. _ ___ ,,. � , _ _ . , .., - - ,......�... �. . ;4 -.�.. ` �- , , � ... . . . ..�,� ,r, .. , ,_... . ....... _... ..... . , .,.•... . . , .'.}.�._,�. �.. � ' . .. . . � . . , . - . ��Ste. � . . ... ._. ... _,...� ; -. . ,� . .. . ,.. . ..�, . .� . .... .. ... � � Q6t�riCC ... ... , .. . . � 3NSPECT�R'5 P99TES , .....__ ._.... _..._.. ... . . . . .. . .. . .. . .... . ... ... � . . . ._........ ...... _. . ........,... .�,.. . ,_„„ ...., .. ....� . . . . , - ,� � . .. . . . .. . . ... � . � ,l � Y' � .. . . .. . . .. , .... _ . . . . , . �. 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