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HomeMy WebLinkAbout1558A _ ; .. _ -- - � :. : ... ... ..: .. .. .�.:. ._ -:: . . . .. <. -:.. _� .;:, . .,. .. .__ .. .. _ �..... WORKERS'COMPENSATION DECLARATION , . I hereby�affirm�ihpt�I �have a cerfificate of�conseni�fo self � , �, . _, , � , , ,_ . , , , , � _ � � � _ . �insure,or a certificate of Workers'Compensalion Insurance,or � �anba2D�- � � - � ' - ' , �a'certified t�e� f"(Sec."3900,��b�.>�nd CEBpB;REV.8i611 qpp�fCAl'fON FO�R PERMIT� � � � � �� �� Policy�No.�_Company �s � �,�.:,; ❑Cer'tified.copy is hereby furnished. SEW�R - SEWAGE�DISP�OSJ'�`Y. ...,....'.'.__ ..._., ......_. _._�.......... ._..... """ �Ce�rfied co s filed with the co�nt buildin COUNTY OF LOS ANGELES BUILDING AND SAF�TY `� ; py i y g inspecfion . , .:;.deportment. �� � � � � � .,.... Dafe" ""'8�20 ApplimniZLS+.�'QeILLE�_ FOR APPLICANT TO FILL IN CONNECTION DATA � � 'CERTIFICATE�OF EXEY�IPT�OfS�R66N�`CNO'RKERS ��� '� � � eunR�N� � L ,) - srnrior+ oearH �C3MP�NSbYIbF�INSUR`Ai7C� ` nooaess �y,, (Th s section need nor be complered if�IFte WOIIt inVolVed I�y ihe � Ml.NHOLE REFERENCE UwER ,"�" perm t is For one Fiundred�dollars($100)or less.) ���'41'TM towea ' �� ' � � "--� ' � � " � NEAREST ' . � TYPEOF WNNECTION�� �� � �ENGTH FROM . . .. .,. .... ... .... . I certify that in�th'e�pe fo'rmance of�iFie-work�for which ihis caoss sr v. Nke P.t. nn.�ro a.�, . - �ipFm I is ssued I shall nof employ any person n any manner � p Na �� i� sa os to 6ecoma s bjeci to the Wo kers'Compensation Lpws. pwNea THE .ANDEPd GROUP Co.iMa.wo �os no. - �� -' �Y ' � �� AD�RE55 PO BOX-3329 TRVNKPERMITNO. ROADPERMITNO. �.. . .:_� :', ..r^. .:..,.r .. ''::. � Date - Appl ca t'� ' `'" " �"' '- . AFFIDAVIT wANER E45EMENT RECORD.INSiR.NO. DATE � - NOiICE'TO ApPL'ICA�IVT 17''ofter mQking ih s CeFtificate �of � � �iTv r.0Y3I1'd re�.No. $18 967—g54i � � .,��mption, you should�become� subject to the Workers' � -�' apensation provisions of the Labor code,you must farthwith �escai i�ioN iorNa. Hwv,oe sr.wioeNiNc � ..,nply with such provisions or ihis permit shall be deemed zC �� ��"reJbked. etoce rencr JJ STFTEENCROACHMEM ... � , '.. ,. ' . . .. �O.OF BLOGS ?ERMIT NO. �' .�.� LICENSED CONTkACTORS DECLQifAYION` � s¢eoF�oT Now oN ioT � I he eby affirm ihat I am licensed under provisions of�Chapter � u5E oF � 9 (mmmenc ng with Sec1 on 7000)of Drvision 3 of the 8usi- eWioirvGS �lYl le �ew�s CNARGES , ' ness 8nd.Professions Code,and my license�is in foll force and y�'�5 �p��.T /y/'��i m � �{fe�f� nn ry /� p CONTRACTOR �,[L,(;��ji'lFy1y l+\/F'��.{.M CONNEC�IONCHARGEfEE '„ � � License Number L�Qpp! LIC.CIqSS__]��¢„ ADDRE55 8225 Beeehwood Dr c REIMBlIRSEMENT FEE o _. . ,...,. m � .. v �O�f�oCiOf 1• Freemat�,e �8/2o/86 .A7.ta LomaTE�No. 714/980-4.429 D�STRIC7N0. GROUP MqP PROCESSEDBY �i1Y - .. . .....,. :. ' , .,.• , - . �/ d g BK PG o , ❑I am exempr under5ec �' � - � � ��of the L.A.Co. SCE:�se No. Q��I48$1 CiA55 , Ci��t (,� � .�. �. . . .. �.. ". ". .. �'�.. ^�p DESCRIPTION OF WORK - ' FEE" ....... .. . .. ,y Pl�r'rdi ng Code and/o Sec. "of the - �.7 OO F�"�A� ,1 �_�6 � V/1LIDATION N - ' � F.OUSE SENlER CONNECTING TO DATE . 8�&P Code for�the following reason�� ���� � �" �" � vueuc se`uea � SEPTIC TANK.SEEP.IGE'�iT OR Z ' � � � iT5 AND/OR DRAIhFlELD F'�.NAL , DPfE _ HOL'SE$EWER CONNEC'ING TO - � � ' eV ' -� ��'� PRIVATE��ISGOSP.L SYSTEM SiCJnOfV e �pNNECT ADDIiIONA(BLDG.Ok - - � � ' � '� OWNER BUfCDER�DECLARAI'fCEN �"� �� �� � woaKTo Hause s�wea' I IIeIEby Off rm tFltlf I om C%Bm(Jt Itom tlle ConifaCto�5 LicenSe EX'NF��C SSPOOIGDRVWELLAIhWNHOie �v��� ' law for the following reasan(Secton 7O$1.5,BUiSf1B5S"�nd Pro- , ALTER.REPAI�Z DR ABANbC1N'HOUSE' " � '""' � `^G""Sians Code): �� �- �� �� SE'NER OR�ISPOSAL SVSTEM y(s ss C e '� J �,.'/ �. ..... :s... .... .:....... ... .. . ... ...... . .... . . .. . , � I,as owner of the properiy,�or�my employees with wages as - � �a�t`r� •�iheir sole compensation,will do ihe work and the siructure , `is not in�ended or offered for sale($eciion'"7044,�Business „ �;;�,..— . �-and-Professions Codej. -� ' � � OWNER'S Permit E ].0 Q ' -- . �U�` � , ❑I,os owner of the property,am ezclusively contracting wirh AUTHORIYATION TOTAL FEE '� �'� ^�•y C�j��� '�iC2f152d contrac}ors�o construct ihe,O�O�ECi�$eCtiOft 70�, :HAVE AT THiS�ATE A CONTRACT WITH THE NEREIN NAME6 CONTRACTOR TC ` �. BUSine55 bnt�PrOfe55 ons CoCIe�. CUNNECT THE A80VE DESCRIBED EXISTING DWELGNG TO THE PUBL�C SEWE2. ' "���`" �CONSTRUCTION�LENDINGAGENCY �����-� � ��� ���� Z —�tiZ7g S � I hereby aff m that there is a consiruction lending agency - SIGNEDTHIS A OF_ 19_ , for the performance of the work for which this permit is �"+NERoa owrve�s nGENz � ssued(Sec 3097,Civ.C.). , . . , nooaess a oma, @2C OCZ �. � .,,. , .,... .. .... , .. .. . .. . .... .,.. ... , lender's Name � � � ,_ . . . . , .. .., . , .r . . � . .. ... �:. '� ......--..,'.�.'.�. .. .�.�..�. , �:.. :.:.. . _.:�:.'.�. , u.:_�:..'.,� .,...�:.:3..:,.. ......... ....l..S.�:..,a.. .�.....v. .. . ...,... . r..i. .�. . _,..� .. . . . ,. . . .. . .... . . . . � Lender's Address: .:." ����_<... ..�: . �.. � .. , ��. . .. '. .. � . �., . . . . ._ . ...,. �. .. ;::,,..- _.. _.. , . ..:. ,..;.:::.. .,.. ._...._ ..-.�. -:....:._..... .... . _ ..,, �:_...: ..:... .... ......: .:.:..... ...:.. ....... � �_-:. . . . �:..�..,� - I certify that I have'read Ihis appl�imtion and�siate thdt ihe - ��� above information is wrrecL I agree to comply with ali County � �� � � � � � � -ordinances and Siafe laws regulating Plumbing and Sewers, ' - - � - � � � - � � � � and�here6y authorize representatives nf ihis County Yo enter � , -, - � � u,'p"n he abov entioned properfy for inspect' n pi poses. ' � ����Q�� ���� .n �y,„ ign�ature of Permiflee D� SEE REVERSE FOR'E3CPCANAYORV LANGUAGF �� � � - . . . . . _. "7.x.v . . , .�� w�=��,,,, . . 'z.:��,;.u;. .,t. ' A . w,. ....; :,s, .. 9i�SPE�1'gR°SP9�7ES.....�_.,...._._,��..:m..._, ,., �V��$-$�ITR,I�EE�°d?��f4.t1R�"�`I�5i4 �.. ,. ._ /4�E�R09b�LS on� iusv�croa�s sic�.aiuiie mmq_.,s,�.,� ._ I d�ereby a�irs�n xa;sr C am�s�.ar�ce iec�xhe i.aaxracac,t's New HousE sew,Ea �� , � Lieense�Law fax�e5�e io:levriag zeacan,Sectsna,7e?31.>, -------���_ ,Bsrs3»eas ar.d Psr�f¢ss%oxs CodeJ.hny cityr or corauEy , ODNNECTA�DI710NA4 ���� � �� � -. � LpJJB{JJ 48QY&tTH.i e pe;rnss`t sc roassr»�ce,altsr,��s�rov�e, +� 9UILDINGORWORK daEfysOliglJ OF;T ^�O1i SlfY163ddTHn . �, ........_$!..._. ep��5: .�iT's�itu e;.s dssua�rece� AND/OY DRASNF EIDT{5) .. �— .. . ^-� . . . ---- ... .. �ISPD +�e abwa�ik�e lecassx fov ssui�..,en�de�8n ja£e a � . .�"� � ._ , ,._.. seg�aed s3a&emeut¢63rs2 t�e a��ic5ees.cG'�Suss:tcr:e;o +be �ss,=oa Q cxrroEii p � —"`— • _ . _ . pr4visio�cs tbe�L'o;::�rssda,�'>-:scar.sa Law lCbm,�+ts.^9 . ALYER,REPAIR,SEWE20R � ' � rComef89f&�'.�f,�s`✓i:+a.iEtG4oYY�Q�(1��O}I}34tlAa�:Gl3�a,jr$.Se „ - SEWAGE DISPOSAL SYSTEM � ' �y$;q;;,SS fe9k6�FYli�6SSIvN3^..OlIBj 8V'sI9GE .i"�fS 3.b'8991�$ . OISWNNFGT PLUG FND ' ABANOOM HOUSE SEWER . aiJ¢iYtfPOfis a95G3$yJe+�i6at&,jc)Y$I32!r'P�6�{+¢2 P.:C2tlb�ldl08i.A.i,^�� .. . "' -vioPatloa�fScrt�a>r:?031.53yustro�appdicantforcperrr.st '.. BAIXFILL SCYTIC TANKS� ,. � '� � SEEP,PRISI❑ cessvoou5 O � -.. . . . sulry'ec kp�licsn :a csaa,�si¢18yr;�f xos mnre 3 e '; . :... � .,"s`.�., ...�... .... .,.... . ,xp �.�y. .. . . ,, .... . . ��y$AdfidYe,��OddAYE'�.�b7���6�J '! . .....� _. . ,..._.. . ... ... ..:.. .... _. ....._. _ .. .-�-'` \ `__"' . .�'_. ' ' LS i,as 3he�wn�s af�tlse yts�2t�eq c�:nftl d5 xlxe wd:k�,and . . -.. .... .... . ., . � . � .� �... . . . . , �.. . � . „;..,•,., _ ,a;• .. _��1:'-�C� � zhx strutinte�is r�ts2 ievYca3e3 9r�offc�ted�ar��. a`1•: � _.,. , .. ,. ..� ._.. . . .._..._ . '... '' . ..'.._. . ... ....... .. _.. . 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