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HomeMy WebLinkAbout1567A _ _ . KER 'COMPENSATION DECIARATION� �� � �� � � � �- � � I he eby affvm thai I hove a certifmte of corisent to self � � � � � � � � � � � . .. .. � ..:.. �.. .,:. .. - ...... .... . ... . . . . nsure,or a certificate of Workers'Compensation Insurance,or' >���6 � � � -� � � � � � � a ce t f ed copy thereof(Sec�3800 La6 C.) ce eoe(�ev eiai) '�� �� - "� � � � - -_ �� � � W..... .,......�......,.. �.� . . ,�,.� ..,�: . . . � Policy Noti�����ComppnyS�Yi �u�a �= APPU�ATION��O'I�"�'I'�1AI�' �y.-py� ...__.,,.,�._n_._._..... . . . ❑Ce t�ifie co is hereby furnished. SEW�R ' SEW�����JI'V��L µ,µ.„. .� ;. .,�::..,. . __ . .. . . ....... ' _. .,,,_. . ._..... . . ..w:.....�..:...:._.,:. _. � ,:.� Cenified mpy is filed with the counry building inspection COUNTY OF�Ll7S'ANG�I�S"��-'��� ���BUILDINC'.�A13D'�SAX�1'Y` .___:_:<.: ..� .��. deparment . . ......_ . .. . .,. ._..._,,... . ... ._:..... , , - ,. . . �..,.. � .. - ���.,. Dare $ ZO H qPPI canf �• I''reeIIl�iib . FOR APPLICANT TO FILL W"' CONNECTION DATA " , ..�..M,. . _... . .,., �CEkTI�)�A7E"OX�'S(E'N"�F�Y��'Fkd��i+��'k-��k��R$' . au:.oiu� ... ly„� sranoN oevrH ... " '� CO/dti,PEN5A710N.7NSUkAYJCE - �� �� noDae55 ' ' . . .... . .._._ .., .. (Th s settio need noi be completed if the work nvo�ved by the �p�q�liY MANHOLE REFE2ENCE �� " 11PPER ' ermit is for one hondred dollors,($100)ar less.) .,�Ow¢k er �. . . , .. .,:.... � . . �_. .... . NEAREST }q . - . I certify that in lhe performance of�the wo�k for which this ttreoFcoNNecilOnt� - �� " j�N�iHFRoti� '� cec555T. t� \ Y. CURB P.L M�i0 P.L. �� p mit is issoed,I shall not employ any person in any manner . � ��'" so as to become subject b the Wo ke s Compensation Laws M1 ��.r /r�p/�T� a�c rvo, ��` .� �• '.:,.. ...r,, ,_.,.... >.,. _ .- . ... . OWNER �y..��-FdAl'1 lrilV VS ... GO.IMP.NO JOB NO.., �YII V -. ; .'�.. _ ,: �.'.. C ':�'. :. .,: ........ . . _.. _ ,,�� PO BOX 3329 _ ..__... Date� ��� Appl mnt - ' , - nooaess Txu�vK vEeMir NO � &oAb aeR�v,iT�No. � . . . ..,.�� . : q�} T� _..._.... NOTICE�TO APPLIC.4Nf If pfter making ih 5 Certifitate of �,TY 2y,y 4a,, ,y��Q�NC ��8 g 7"' �q. AFFIDAVIT `NAIVER EASEMENT RECORD.IYSTR'NO. �ATE _. ....... _. .. . ..�'. _ . .. ... ..... . ..... ^�:,�,ip�ion, yau shouid become s�biec! to ihe Workers' ��Ai .�pensation provisions of ihe Lobor code,you mu51 fOft{tWlfft OESCRIPTION ' LOTNO. HWV ORST WIDENING ' ' wmply with such provisions or ihis permit sholl be deemed ....::..-' ' .. .._......_. .. ....,.rLVoIteCJ. . . .. . .. BLCCK TRAGT SiATEENCROACHMENT " . .. .� .....�.. .. . � �; ���> - LICENSED CONiRACT0�R5 D�CLARATI'ON-` � ������ � ivo eF smcs � ��� �� � PERMIT NO. '� I hereby�affirm that I�am I tensed unde provis ons of Chapter � sizeoF�or NOwON�bi "� ' �' 9 commencn with Sechon 7000 of�vision 3 of ihe 8usi- uSeoF �"'1]],$• R8$♦ � �---� �-..___... ... � 9 I BUILDINGS .. . ,,.... . ...., CHARGES . . � ' nes5 and Professions_Code,and�my license is n full force and .... ... ,.,� ___ - "' e{{eCf. ���OO� C34 CbNrRACTOF ',��j�jM� cON��� CONNECiiONCHARGEFEE � - � , Lcense-Numbe v�� Lc Class � � '"""'�� a . , ., , . ADDRESS . REIMBURSEMENT FEE '� ' ' � ' �� Contractor T. ���reemarioafe �-" 8/20/86 � . iE�No. �1 ap����pG,J �iSTRICTNO, GROU? MAG PROGESSEDBV ��� V ��T� A:lta I�oma � )� sK P� o . . . .. . ' � SiATE lIC� / � ❑I am eze pt u der Sec � of the L A Co �,�hSE No.474887 nass� �' s ..,.-...:: ....... . ..... .,..' ... ,�......,.:. �.,�'.. NO. �eSCRiPTfONOF WtlIYK . .._._kEE,. ... .. Fi � - �IumbinqCodean�orS�ec ofthe ... .. . , � , _, ' FINAL " 40USE SEWER CON4ECiING TO� "'���" ' , _ B.8 P.Code for�ihe following�reason �� � - � vusuc sewex ],`7 OO °ATE !t�*�--� VALIDAT ON . , a SE?'IC iANK,SEEPAGE PIT OR ' � � ' �fe'�� � " - � " ' vITS ANO/OR DRAINFIEID' ' FINAL ' . � , HCl15E SEV/ER CONNECTMG TC ' B� - � � � ' - ' PRIVATE'Ji5PO5At SYSTEA1 � - $9npfufe OW�E _..._.. CONNECT A�DITIONAt BIDG.OR� �' �" �` � ..� :":_ .: R BUILD'ER�6ECIRRA�TI�N. . .. . .. '�n-oxK TO Ho�Se Sewea � , � . I hereb affi�m thot i om exem t from ihe Coni ac�or'S License ovERFtowSEERnGE PiT,�qA�Nrie�o . Y P EXTh- CESSPOb�,DRYWE[L;MANHOLE� � Law for 1he following reason($ec!on 703T.5;Buisness and Pro- niTea,zeania oe naalloon��youse I� �'��:Ot13 COfJ2�: SEWER OR 615FOSAL$YSiflvl � � .���r; � �I,as owner of the property,or my employees with woges as� � � � � v their sole mmpensation,will do the work and the siru<ture " ,,� is not intended or offered for sale(Secifon 7044;Busi'ness�� � � � � ,".,U '. and P"rofessions Code). Q}/�/NER'$ Pe�mi} S ].� -rj0 ' " G��S ❑ I,as owner of the properry,am excl�sively conlracting with AUTHORIZATION 70TAi FEE 2'T 5Q •. :: <�i 7:,:,�c; - licensed Coni!'aCfOB to consiruct the project($BCtiOn 7044, ;HAVE A'THIS DATE A-CONiRACT tiVITV1 THE HEREIN NAMEC CCn'TRACiOR TO q(� � 8usiness and Professions Code). cor�nE�?THE ABOVE'DE5'CRIBED'EXI$TI}7"G���N'ElLif�IG�iO"TI{E"p'�6BCYCSF`NER�- �� � �l i]i y—V C � CONSTRO�TION�LENDING"AGENCY'��'"' "��"�"�`��""`�"" � n o I hereby affirm ihat ihere is a construction lending agency SIGNECTHIS ` q OF A�� �--� �q06 � for ihe performance of ihe work fo� which lhis permii is �'vhEROR OWNERS AGENT issued(Sec.3097,Civ.C). , eC Wp0 J �. a ma Lender's Name� � �- � AooeESs •� . . _._..... - , . .. ' _ ,; ... ,.. . - : . _ t. �:-: :x .. .. _ ..�'�. . . .. _ . .. . . . LendersAddress ,. ... .. . . ...,..,...,.,,-,................... ...«..._...w._...._..a.�.,,...«.._...,.._... .� ,..�.....,._ .,.._.».._.-........._..:.y__.....,.,.......__...,.,...,.. .._.......,..................�.. .:_....... � I cert"rfy iha� I have read this appli<ation ond state that�he M above informafion is correcf.�I agree fo comply with all Counry � ' ordinances and 5(ole lows regulating Plum6ing ond Sewers, . �and�hereby au�hori e representatives of this County to emer . � � � � � z up' ' e abov Mioned properr forinspection purposes; �L��j 9 60 ���" _ . ., . ... _ ....._. . . .. .. ... ....... Signoture of Permitfee Dote � SEE REVERSE POR EXPCANATORY LANGUAGE"������ � ' � � .. ... . ,2. ..�. :.... , .,. �.. ..«__... . ,-..a �.�a ..rnv.. '."�:.3' . . 'o-A' fw"�4iyi tv"�.` ..nies °d.rTGl;,. .'R.�`I'�d�`&9'..a^,`'�n"'�.�c/.q"' _ _.i�'`�'w e!"a::.�.�i}. ,. ... .�� ,, �n�srEcro�'S PfOTES . , �$$-��'ILi3�I8�EG�,�.YZATIUP+ :,- e. ,., ..� . ... . . ..... ...�._ ��'� ,y'�•r� .., . -,�-�.�(��.-o � ; 4�..,w .c , . .. � .. .. . . � , ».,;.. ... ,,..„ � <. , -�� � �PFROVAi$ on� �Nsv�cfoa�s sicNn4uaE _ I hereny affif:o zaac i am erce�pt#rom ehe£:ontrac¢�r's w.. .. _.,. .__ ,..__...... . ......... .. License Law for she ToLowza�zeawrs l�ec�iosa 7a31.5, t�w House seweR � ]4as.rinas.r astd,Profasx6axs CouSef: Azsy csty or coxaNy . coN�ecr aoortioryni � . ,_ . . . . ...- . . .. . .. . �� '-iwbJeb reqeseres a YSerwsit sa c��s2zvred_�¢te�+,improue, BUILDING OR WORK tP¢eROlISCl�br-rz�atr uny sasv:.:nar�,'prdor�sa n��ss*us++ce, .;;' sEvriernrsc.s�v.eiT�s,e' ,..._ � ..-.. .. . :. . .. �. . �...�..�. . .. � . _..,,�..... .--: .. slsn reqris�s ei;e:tpplitrast fur suc�pErmst ey file a AND/OR�RAINFIEI� . :. , .. .ragxad sedtesg:aat E&ap he is Jdc�arszii prrcrsuatat So tbn, . .; . . . � .- . .. ._`,. c¢ssroo�❑ oevwe��(3 �.. .. ..:. ...�...... ... ..:.�.,.......«...,_,....,,..:.:,...,....,... .:_._ ,.. p�nvdsio�s af t5�Conzr�utar's d�asersse Law(Gba�ter 9 .��'' ALTER,REPAIR.SEV9ER OR •.�. ' fCD�/iMC'77L7'+b,4`'GJ�$P3.SBGn09d 7000/af 7'l:vrseox 3 aJ ibe " SEWAGEDISPOSAl5V5TEM . ..•.�•.....-... ._•. ._."...,�•'"••:•� �.. ...••.. ..... �4PSiife56 AK[�cryTOf¢!S%O'+is 4odej ar that!le!s aseempt ess - ., DISCONNECT PLUG AND . :- ' . . . .$�60efrom ssrd t3xe 3�rs£s}ar��e uX.ieqed c�emption.Aay '�_. aaallooNNouse�we�t . ...... . ....:.._...._.. ..,._..,....:._...._.... .,;:;.::�,.,;.,,�ltiotad<'onay`S¢cadore703i.5 33'sayapplicanzfora¢ernsi? BACKFILL SEPTIC 7AN,K5� . ' . . .�, . . SEEP,PR�S❑ CESSPOOLS❑ . Y... ... _ b3L`ofeGCY:S.l�.2�,¢Iz.°fSSi$6 tE tYY33��j"J69§4Id'y 5�W0$mEOfC SF�qf3 .:: .. .�.; �� . :-' �-snH u+ibPo1KM�-+Trr+wr..w rv .z. .t�sxt*MY:s_ -ua..._., .�;� y _ w.w.W,r... ' :- �MW�eM.� .. . . _ ... .,.:..u'�f#P,�x. 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