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HomeMy WebLinkAbout1568A , . .. . �.. ,.�.�. .x�.t:;�>•`,. <��:�':: -�i... _. .,...:.ru� .y :.;�, ,..r � ..-:- .,,,�..�;rw��u�, -, . . . ..,� ........ .. , � . .. .. .,. .,.,,.,... . .. ... .. .F',1�fih'x:A."k6 p„�,;;Z„+'g.w..t ��M�]+Y.-'m,�.�.,r,'�?':h �.._���. . ..:........ . ..._.._..: , rt>..�, -Ch� +�. i .,.... .. WORKERS'COMPENSATION DECLARATION � � � ` � . . 'a��✓�kx+f�A�°�hvaa:e�.vR'4�'�9' ,s. ,;,-,. .V, si.�xsui£ .f3�%�T't'm.rx I fiereby�affirm ihat I,hqve p certifimte of consent to self:. . .. . '. .. .':..'......".'... .-``.�..< . - . .� ..�� ..... ...N. ... . _ .. . ,.... .. . _. .. . :..._.,. .. .. .. � nsure oracertifimteofWorkers Compensa`tionlnsuiance;'o`r" �'�������aa2o �� ,. . . , � � �' � `._` �-�, ��. '�na. ��B`°�,8,8" APPLICATION. FOR PERMIT a cert f ed r f(Sec.3800 C� policy No.� Company,__ ... . .. . ..,,. .. . . �y � " SEWER SEWAGE DISPOSAL _�_ .. .. ., ,,. _. LJ Certified copy�is here6y fumished. _ .. . ...... . ..... . :�Ce r fied mpy is fued w�th ihe county buildmg inspection , COUNTY OF l05„ANGELES,_ BUILDING AND SAFETY , . �cleparfinenL _ . . .. . , . . . .. ...... ..._ ... .. . .. . . _ . _. .. . . . . . , �... oar� 20 8b Applicont T `"k'Teem219 " FOR APPUCANt l'�F��L�Fy � "" ' CONNECTION DATA�` "^�`"''`""'°''" .. n, _ ... . .x• CET2TIFICATE OF E�fEM1P71��!"Fi�(.j1vt�NORKERS � aunoiN� .... ......`. _."•^••'.. �/ ` .... ..._....._.,. .,,..-.......>. ,...��,pg � �. . ... .. . ..•,.�,-. . . . .•.,Ji STATION DEGTH•.••»m++.vf.SYnb"cwa- .��CONiPEN5A710N11�7SURANCE � �-'- --^� nooaess -�, ...:�.. .r.,.. _...,,., .. . . ,,,, (This secnan need not be completed�if rhe work�involyed�by ihe, ��� ��� '"�� � �` nnnnNoie eeFekeNCF ���� "��- � -� �"""`6"�'°Q uwER �Serm t is for one hondred�dolla s($lpp)or IESS.J ���A��TY _ # ^ LOWER .".."' fJEFRESi F •.."�.• •"` .� ��. ��.. TVCEOF'CONNERION -` 'M1tlMiw� I cert fy that in the performance of the work,for,wh ch ihrs , caoss 5T. -4"� v. P` �a p�o+� , . . ..,..,.,. .:...NRB peimrf is issoed 1 sholl no�employ ony pe son ro any monner - �. . - ..,,,„.,,.�.,,..,�,,,,�„_,., ,,, ,::,�.,� ..„........._„.,„,,,,,. �,�,,,��„�.. .�4r.��. , . �so bs to become sub�ecr to the Workers'Compensation Laws. �vdtvea f]j1T]��i'j�1j co!nna.rvo. �oano. ��v ���� ��. �. �' .� �. , •��..� ' � . ,�''�l .PO �JVA 2 . . �'�N� TRUNKGERMIiNO. '" _�•:�•. ROADPERMIiNO�Y�~���������� � Date� " APplicant :.� � . � +DDRE55 - : .�y ...,,.. .:..,... x .....,., .- .-.,W..- .. ..._:...� �,,. ,,:�.�i ,M,.. ,_.:.',:: AFFIDAVIT WANER EA$EMEM RECORD INSTR.NO. DATE ' NOTICE Tb APPLIC,dNY �f, after making this Cer�f cate of a�v (�4Y1T1'd ��va� .,:, �,mption, 'you�should�-become subject to the Workers' iEGA� �—'���"�" �-. �'.""•'.�..:- .-."'._.,�- ... .. . �pensotion provisions of the Labor code,you must forihwifh oescaivrioN �oTNo.. " '"���"'""""`""'"""°'"""`�""°'"''"^f0 � � � � �� ' HWY.ORST.WIpENING ��mply wirh such provisions or.Yhis permit sholl be deemed � -��-�•---� � "� '-�� �� - - 'leV'OkEd. BLOCK TRACi S`AiEENCROACHM.ENT �""`��"'�"'""""""`^`• .�"� � �`' ' LICENSEDCONTRACTORS�DECLARATION' �� � ' �� ' """ � PeemirNo. � - y � 4S a�� ' No oF siocs. :.,... -,,�.. .� �.:... .. . SIZE OF LO7 NOW ON LOT ... . -. ._ . . :: ��%.'wtsa+war�r I hereby a�firm ihot I om licensed under prov�sioris of Chapter� ����� '� uSEOF " """•^ ""_""""^'^"`+ ,"'��'.^'`<,="'�w w:-�,'^%fi:.*; 9,(commencing with Sed'on 7000)�of�D v's on 3 of the Busi_ Pwio,r�s 3,j� �� '�- ' �"�p{��;�'�'�-"'r�""'s"^� � ness'and P ofessions Code,and my license is in full forte ond � - ...,-.... . „.,.,�..,._ . . ., , . .......__.,„_,._,,,,,,,,,,,,,,,,, ....,� �-effeci .. .,�. _ ,� .,;.,._..,. . .,... . ._, . .... ., cON.Ra[7oe k'�i,'`.� .. ............. ..:.. .. . . �.� A CONnECTION CHARGE FEE ' ,.�, ,' :.� . . . . _ .......,...,.�...,...:..».,a..:e... � .:�...�.a.:. ._ . .��«u,NeR,.,..,i,..,..�....:Nrm.ar.x.'4e�MF� 4 License Number �^Q��I48H�I �IC.C�453 �4y_ AODRE55 � �� REIMBURSEMENT FEE O �. .. �1 1��'.BBIDC�TA '.:�. V/2OIVD �.. . . .. q�} ' RO MAP �....._ PR .' v . Ca�trOC1oI • DOte ..._.l` CITV tyy y'd. (�n] TEl NO. .� IST CT NO U BK � OCESSE6 BV Z D RI G P . . .:,,. . . ...."..k._ ..x,. t,�y ❑�I am exempr under5ec. � �� of�the L.A Co.� "� i�ehse No.. a�48�7 � Y� c��nss �i ✓(� O ... 9 ..: . g .- .- . ,.; ,-'`... ,,. . .. _....., _ V Piumbin Code and/or Sec of the N�� DESCRIPTIbN�F�WORK �E "� FiNA� . '.'.,, ... .'.". - � FqU5E5EWERCONNECiINGTO ���" � OO DATE II^'�S VALIDATI N 0. �8;B�P.Code fo the folb m redson ueucsewea �� � _ _ - SEPT�C TnNe SEEPnGE Pli OR .. '. ."""` N ' oiTS HNDiOR DRAINFIElD Fi�"A� Z . �.-Dq1E o.,y„5�,.:;� n.,c..y.,„,,;,;,,s. HOUSE SEl'JER'CONfJECTIN6 Tb, ...,•" . ..••.• Bv . . '' ' w.,., .� - �.. ' FRIVHTE Di5.05'AL SVSTEM $iCJnatUle � ' ' CONtJECT ADCITIONAI BIOG OR .. . '. , '. - .. .""^"..' . -..�«...... :�_,,.m,...,... .,._,.,.,,_.. . ����" OWNER BUIIDER DECLARATION ��' �-�� �•�� �^ioRr:ro House 5¢wea � , �:;.. -. , . ...,.. .�...,. .. OVEkF.OW SEEPAGE 71T,DRAINFIE.D ' ` . I hereby aff rm that I am e�empt from the Contracto s L cense ex*rv. cE55vooL'ouvweu,,w,NHoie � ..... ,�... ... � ��� 'Law fo Ihe following reason(SECtOn 7D31 5,BVISne55 anCf�ro- ALTER,�REPAIR OR�AgAN00N HOUSE -- ""`" �:, j �'6.23�, � I�'�:'Dns COde)' � ' �� ' � SEWER OR DISPQSAL SYSIEM ._....,.....,...........z...�.A,.-,�..�,.+.n�: � � .� I,as owner of�ihe propert'y,dr'7ny Firriployees wiih wages as �% ' "' ' � � '� . . fheir sole c,ompensafon,w II do the work and the structure �- � "�'` "'� °� is no1�intended o offered for sole(Secfon 70�4�usiness'������" �� � � �...._ 1 �' '�C 1.J% dnd P ofe'ssions Codej.' " "" ' ' - OWNER'S PCrmit g ❑I,as owner of rhe properry am-exdusipely contracting with , AUTH�RIZATION TOTAL FEE �� ��� 2 �' " ' � ��`���= � � licensed CO�tIOClO�S�O tonsfruct fhe project�$BCiiOf�7�44, �HA�AT THIS DAtE.A CONTRAGT NlIiH��THE HEFEIN NAMED CONTRACiOR i0 `�j�7_,(J L ' BU5ine55 O�c�P oFC55 ons COc�el. � - � � �ONNC{i TNE ABOVE CFSCkIBc6'�XI$fING�WELLING TO��!E PUBLIC SEWFR. �� '� �� ��CONSTRUCTION IENDING.AGENCY� � � � tf o ► � � i hereby aff m fhal fhe�e�is a canstrycfon lending agency � SIGNEDTHIS D YOF ��b � 19 v � for ihe performance of ihe wqrk,fqi�wh ch "rhis permii'�is ownea oa � � � ..._..... ... .....� owNeasncEnr �ss�ea�se�.so��,a�.c.�. A�pqEs_ 25 Beechwood Y'.� 1�t3 OIfl2, �r Lender's Name� ..�. .�." -, . .. .._. . . - �� � . �. .. , .. . .,�.,..... ....._,..., ... .. ............. , ... ... .,.. .. . . ;�m�&,`k+�. "i�1t���e✓�k6. '�5�+.59r�-aG+��''�,..s n.�'s�'r�-�'a� - Lender s Address � � � � -� - �t.�',r,�.�s;i�'i I ce�tify Ihat�I�have read�t�his app�icafion��an�"stafe ihot�t�ie�. "F"'. ""."'""" '""w '°^*'� "� ��.� h,_�-..�,.��- «.,,..,._.,.. „.�.�a,,.,.,,,,, .���w,�,,w,���a,� . ..,,. . ^,.. ' -�«:.e....•..w�.....w...s....�...,.,.,.,...., � ;, above information i5 correcf.I agree to tomply wrth all County� � '� ' �' �� ' -'-"-�' ��-�� � � . , _ � ..... . . ... .. . , - �ordinances and��Stahe laws,.�regulp}ing Plumbing and Sewers, - � � � � ,� �� dnd hereby authorize representatives of this County to enter � � �o� the pbo entioned property fr�Pur oses. � . �... Y�NIYI � l �.��."-"..':.. ignoi�fee .... ._. .Date SEEREVERSEFOREXPLANATORVLANGIAGE ' � ' � ' - ' .,, . �, :.'.� ',;::. . . ' . , . --_�_._.�_��-.._..�.__.._.-._.�...�....,-.._,,...-n-....-.-.x,.,..,._....+no*a�,.r.�,.,s...w.�.s...:�• .�.�-.,.,.�.....�. . .. � , _ . . � .::,....:_�...:,........� �.:,.,; ..� ... �. _�.,.._�.,....,.�ti. � ��� ,,�:,,.�- �.. ...�.:� �n,.. �,;�=� � 4�.. � � �.�_ ��a��c,r���s�o�� ��v��c�r�,����s����.a�'�ear► . A,F�IP��VAL� UAT- INSGEC'fOR'SSiGNP.Rliffi .... ' , � � .r heeeby�a£iirzrz rstae)sm�affi�a7.f�ani¢B�p n,exniractar's b a � �W:dDUSE SEWER � , —. .. . L3CC316C L�W Y4Y$SE£�LO�10��5�YFl1S4DlE y.S¢C$ibDd 7::33.5, . '' BIL�GORDWO4KAL .,.,u. .�ysus"se�x :mrt PrOfes;iar.s �ar�e�:9wy eitg os•mufcty ..: ' . .. -.... aoJ�9c3s ra�raerss a yes°nzdt t�crxa,£ract,alsea•.�asprove, � .� . SEPfIC TANK.SEEV.VYT(51 ..,-. . . •.�•.•.�• 8j7(f3P��S2YYi4'Y'td252r.�I'fOff..f(q Z1S"lSsfiII9EC6. ��: AfJp/pq DR4INFIEID . . �EMSOYYS�i�1`2' `� — � . .. . . . � .. .. atso rsqusres ave:agi,�ifs�r�a,jr�r s�arE�¢rma?to jzPc a '-, tEssvoot O o�vweu(J _ , . . ' • . ,-. . - signed strateaeaeat nera;��ie a�tice.ra!srd jiaer�va�z xb tPse �� SEWA^vED5�PO5ALSY�M ^ • . . .. .. �!'Po911b'40:'73 Of'L°ay8 i:'v�aY.TZ'�OYS 1LC6E9iS@ Ld'V!9CFhR,�7fEP�} � � ,�'casr�:ns�ri�g ueEa Sectecxi 7060}�f ISivrsioms 3 of Fbe . pISCONNECiPLUGAND Y_ Ef653#85Y RW�F�Y�3IE&g;ip},�S �rzd f or that krE ds ex�mpt �. AeANDON HOUSE Sf1NER -. � . � ' .�. sX3erejrcwz aea�:1re>Lms�t•fnq W�e a!lagerd r�,¢61nva.llxy ' , . . :. '�.. - .... . oiolatiom af 5ectsi�7031.5 by�3'rtPplisauzl`osa p¢s,mit . dACnFILL SePTlC TANNS Q , '�, gEP PTIS�O �CtSSPOOlS❑ �" . . �..., . . _. -- �n � -- .. . BJecta 2ha '"a�v sa rz xr ,bsnuYy,�of s�o�unare t�hax '. "' -.��. "^YB d 55 . . ........... ......-.. .. ..; '.. . ... . . ,.i l`s�humdYEd d'oduaa.a(,�7f10%: . ��- �, .� �.. `� , ; . ✓. �..``" � .- -. . 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