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HomeMy WebLinkAbout1559A (9) ....:_,. ,.,. ,_,m ,�. , _. . � , ,. _ .� .,.:.. ..;.. , . . �<,. .m -. .... . � ,-,>-� .;.:r.. _:.:��,q �.�.:�. ;� ,,'. �, :..,e,� .� �,.g;w,�;. WORKERS'.COMPENSATION�DECLARATION I hereby a#firm'that-'I haJe a cerfificp�e of consent,ro self, ._ ....,_.._.. __..._.....__ .._.,_. ....,_ ......,... � .....%'baGdTD.. ..,. ......... ._..... ...... .................,....... - .,......... _._. _._... � insure,or a certifica�e of Workers'Compensation Insuronce,or - atertifiedc �t Sec:3800,�ab:.�F��d �EaoB«Eve-e„ APPLlCe4TIOtV FOR PERMfT Pol�ty}�1 . ompany � �s p . �' ❑Cenified copy is hereby furnished. SEW��I - SEWAGE DISPOSAL .:.:.,.. .. .. �I Certified capy�s filed with ihe counry building inspection COUNTY OF LOS ANGELES BUI.LDING AND BA,F„ETY bate��Z�e��$6 Applicant �• �re@m�17 FOR APPLICANT TO PILL W CONNECTION DATA - CERTIFICATE�OF EXEM4�TI6N FR6�'WORK�RS',��� ���� � �,� euuo�.N� � � ��� ����� � � � �� ''�� ���'�� �:C01vlPENSAT161J�IN5URANCE - � � - `�� � �� ' Aooaess � s�nnorv ' '�� (Th s section need not be completed f ifie wo k�nvolved by ihe ` vaNHoie aEreueNce �PP� DEP H � permit is for one hund ed dollars(51001 or less) ioca.urv , - towea NEpREST . .. . . � TYGEOFCONNECiION, ....,...._". ,..._,....__........_.........'......_ c�- LENGTH fROM �1 certify�ihat�in �he perform6nce of�the work for�which thi,s ceass 5T. .JV V. CURB -P L. M.i.TO P.L. " �p'ermii is issued,I shall no1 employ any person in any manner � � • "so as�to b eome su.6�ect to the Workers'Com ensation Laws. r��+ �➢�' �+,RQ� v.c.No �n,y� ,S�, I P OWNER CO.IMG.NO. JOB NO. �. - '.. ;: ..'. ,�..:. - . . . . .. . . . . ..... ... . ' � � �:. .. '. . .- ...� - NJIL ^ ' "'" ' ' ` ' ' -- AD�RE55 , G TRUNK PERMiT NO ROAD PERMIT IJJ . Date � Applmant � �� �� " " AFFIDAVIT WAIVER EASEMENi RKORD INSTR.NO OATE NOTfCE�TO APPLfCANT �#�after making rhis Certifiwte of ciTv Covina re�No.�18 967-9 Z. � ' ���mption, you should become subject to ihe Workers' � tEGn� - �� � � ��� ���-��� � ��� � � �� � `i ehsatian rovisions of ihe Labor code,yoo musr forihwith OESCRIPTION �oYNo. � � , P P HWY ORST WIDENING .nply with such provisions or this permit sholl 6e deemed � �'�'revoked. e�ocK TRACi ��� SiATEENCROACHMENT '_. _..,. ..... . . .. . ,...-...... , PERMR NO � � LI�ENSED�CON7RACTORSDE�CARATION�� rvo:roFeior,s""' �" "� . _ , :. �',,. . :,. ,. ..,.,;...,. . . ... , cIZEOFLOT NOWONLOT " I hereby offirm ihat I am licensed under��provisions�of�Chopter uSeoF " � �" � -����""��" `' - '� 9 (commenung wifh Section�000)of D vision 3 of the Busi- awmiNGs �1ZS��..E Rese CHnRces � � "' '�ne'ss�and Professions Code,and my license is in fulf force and ��,t�y;A�T �T ry�-�--- --� -� ' ' ' � ' ,.-�'CHBC�. � CONTRACTOR" �RL'1'lA'll'1.LV COStl S 1• CONNECTION CHARGE FEE } �7r}A p �/ /[ A 6. LiCBnSeNU 6e `4!'FV�! LC C�a55 �/�`'�' p�jn �„, REI'NBURSEMENTffE , m �j . . . A��RE55 (]GG Beshcoowd♦ Ll e o Contracfoi 1• �re'Eman �O1E \�/�O�`�� CItV p�,y`a, Z�ma. 7EL.N0 714� 980-�429 DISTRICT N0. GROUP MAP � oROC'ESSE�8Y � v ,-,. ,:;, ,, . :,; , aK � z ❑I am exem t�nder Sec of ihe L.A Co. S�ATE _ u�. y� o . .. P . . ���ENSE N� 474887 ��A55 Cp . .. �V ' '�� � No. DESCRIPTION OF WORK ' � FEE ' ~ Plumb�ngCodeond/or�ec.� ��' � ofthe Finni � , � � �� . � � .' � HDUSESEWERCONNECTINGtO '� oo 'JAiE //_��Q/ VALIDATION B.&P Code for�the following reason� - ' � ?ue�.�C 5ewex : 4 0�� - . SEPiIC iANK S:EPAGE PI?OR � . " �- PITS A�1D/OR DRAINFIE:D Fl�AI ? . . �ate HOU565EWER CONNECTING i0 ' "� 0V �F . ' .. ,„ , .. . .. . PRNATE CISFOSAL SYSiEM, Signa}�e ,, CJNrvECT ADD!r!ONAL'e�DG.OR ' � � ' ' � - ��� OWt�lEk BUICDER�DECIARP,TICSN � " � � Wa+K ro Ho�se sewea ...... . .� . � GVERFLOW$EEPAGE PIT,DFAINFIELC I hereby affi m thdt�l am exempt from the Cont attor's licen;e , .'� Ex?�..cess�t.oevwe�L nnnNHo�e "" Law for the fqllowing reason(Secton�OS1.S,BUi5�255 CJ�(�P�O- Ali%R,2EVAiR OR ABANOON HOUSE ���� ,� �Sions COCIE�: SEWER OR DISPOSAL SYSTEM ;`�C ' ' , I,as�owner of the property,or my employees wi}h wages as � , W .iheir sole compensation,will do the work and Ihe strutture- f; ;� ., � e 1 ^ � - � is�not irttended or offered for sale(Sec}io,n 7044,Business v ' �'and P ofessions Code). ' � - � �WNER�S Permit 5 ]„ � - c.� AUTHORIZATION T � "`� -;,G' I,as owner of ihe property,am exclusively coniwctinq with �TAI fEE _ � Q �licensed conhactars to construct the project(Sedion 704a; I HqvA qT T4�s DarE a coNreqcT wltH rMe He4E�N NAritEo'CohTencTOR*o � - '� �`,�:�.�'i u BUSif1255 OlICJ ProfE55-Of15 COCIE� CONNECT THE NBOVE DESCRIBE�E%ISTING�'lJEILING TC i11E�P�&IC SEYJER�� � � `�� CONSTRUCTION�LEN6ING AGENCY� � -"" ��� ' � 2(((��� �u ��j � ( ��. -4�.`"7 E� ' I hereby affirm ih61 rhe e �s d�consirucfion�lending pqenty SIGNEO TH15� �i f g 19_ for the performance of ihe work for which this permii is owveace �l�rn� - issued(Sec.3097,Civ.C.). � � owhEes'aG.eNt aooRess ���IIl�� 22C�11Y00 DI'. ' Lender's Nome � �� � � � � � - , ., . .. . _., _ , , . . ,...... _.,, . , . ... . ..�� � �. . �,�,. .. .. . ... . . .. � .. . � ,�. � .. .. ..... _ . _ .._ . .. . . � � Lender's Address .. . ... . �... ..�... ,�_. .. , , . . ., , . . ., . . . . , � .,.. ,.. . . ,:.,:...:�:..,.. .... ......,,., �-....,......- - ..,.,,_,. „,..., .�...,. .....:-..,.r. ...._,.. ..,.,,«.,..r... .. ...... .., ,,._......... .,-.......... . . ..........�_.,._.. I cerlif�Ihdt��l�have reod this��application ond stdfe-�that�fhe� � � � ��.. Y . . .. . . . . . . . _ . ���a7iove informpt on is correct I agree to comply ith all Counfy � � ��ordinances and Sfate laws regulating Plumbing ond Sewers, � �and hereby autho�ize representatives of this�County to enter � ' � � � - � � �� �� � - ��� �� � ��" � ��� ��-- � '�" "� ��"�� -��" "���� -- ���- � u' r�the abo�e-r�entioned property for inspection purposes. � � I '� . . ignature of Permiftee � � ��Date��� � � � SEE REVERSE FOR�E72PLANATbRV LANGUAGE; � � ' •, _ _. _,,. �a;... , ....,. ,�,..,,. � ,.,�a � . 8N5lELTOBB'S BEQYES ..�`�lti'��-��7l�.dq14�l:l��.k�''Pb.���T � . . ^::v ::e..��% s._,�.:. . ._-.....� ,. :, .. AP�ROO/e4L$ on� INSPECfOR'S SIGNATURE I I3QyE�ij��If£'Y�C Y$8K 4 8�9�BCISY`52?�a�z tF3�e Lo�teactox's N�HOUSE SEWER � � LiC@fl8C LAW YCY'.3te SOi1fVq°ift�S�E95611➢�.S@68Y{�y 7431.g, � � CONNECTA��IPIOklk - BuSeR¢u 6,"��YO�C,R3%GD'.d' a'�e0!{Oy�9f� ClL,� OF CO41&l'f� BVILDING CR 1YORK . . . . ���b�S'�e 6Y'��',f�BP%:>t`�O Ce?YLC�3.'aYC,br+'�gBPe i9Vt$fOilB� �GTiC TANK,SEEP,PITISI --. �CIkOIdS��akY Y9`�tlJY`��+StfCBCY£iY'Er 2�DT>0 2L3""95S8t4ttCCr � ' ' AND/"..R DRAINFIELD ql,qo YBg4diPUS FSJv q��G6YFE,fUf'Sf4t6F!f)gy9ffi3E M�12 A ` ssgaed strsrcnawzz 36aR ha 4s laterued�sarsares�e tn the � cesseoo�❑ oxvweu❑ . , . . . . . . . . prooisrons nf tAe�a��rrugor's•Lecasase Lasu;'ChajiBer 9 . ALTER.REPAIR SEWEROR SEWAGE DISPdSAL SVSTEM �rom��n�&'�3��'$r$K'+�.i�DO)of d33r�esic�;3�sf tbe Gi BRSI938SS G9d(I LyYOfCSSYO;%6 �OdBj 6T�J(Li'klE JS S#BiR�t A&4NDONN HOUSE EWER �� . BbeTe�4VPiB II14d Y'd2 FIR.SgY�f3Y 8I5�RJI6�B[�A%�ibY�LtO�.C156$f � BACKFILLSEMICTANKS� " � - -' v10IOSi0itO,fS2C8'8.'LR7O�1.y'.l�`A9t:���/�.'.feY.C�0Ys8�J6YiN3C ��. ffEP,PIT S)❑ CESSPDOLS❑ ' . . .. . S16�feG&S E�JQO� JfCdkYR a°v S ttflld yhBSW}�LS+Lj`'A6C 8]tOPE PbSf'# ' ; ��Snssedrer��doJ�aas�55'Jc3#.: _. .. _ . , � _ -:, , 4 __ a . �� • :. . I,as s1:2 rrwatea of a:u�e�r wi[7 do Yf�e�orrk,a�u .� . � � .. � . .. .� .. : .„. ",..,. . ..�.. .. t�ez stract�rre as not�+mtsaded ox offered for sa�. . , . . _...... �, ..... . -� � . � . - . . -._ ____ . , ,. . . : ,-....�:. � . .. .. , . -...� ..�... . . ... ... -. .. . � ."�7 �� /Sea 70$4��Busiwex.ttrart'Pro�"zs.6nses�G'ade:Tl.'.can� ... ... ' ..t .,�.. . . . . . . �. . �. `. .:.. . . . .. �. .. . --.. . � . ..: . .. atPor's ' g :u daes ate+t ''tc u+ . . . � Sl '- . ,Iacees Ia � sj3 ty ,mn . _. ._. .... � . . . , , .. P � - .. . ..... . ,;'.S �� . erty wibo besxlds nr xnai5rocvs 3bereon,ased wbo does , '.. D�p ..��. . ...�. .. . .. .. . ... ..'.�,' :.: . ..... . . . .'.,, srecb rvor�liaettsadJ fYr»vided PIrBt sucb ssnp�ovementa .. . ._ . _.. . .� . � ... � � ar¢fiot oraderrded av -�.:. .. �... .. ...... ........ ..... . .� � - � �rr�;s. �_ busTdin or�sm "��ered Ja de, d.roweuer, o . r sa If, ' bs - . ..., ,✓ `'!.. . yt+averrsea!rs su7d suetbix+r�e�y¢ar s} ,� .�,�.._�.. .. . ., ,. ._. , .. ..... . ._ .., g .. . . . ..... _....... - - . . . - - . . �. ...:�. �.,.. m )ezro e buald d7 bav dbe 8urdes� : . � .. .. . enp az. tb. e�waeri er uri .e . . . ,. - ,��.� .. . . . .:: . �. ... �. � � . , . .. . �� ., . Of jSPOiltMg tIJ6P�IJB JSf[I�OE St6iIal oP im�save jas she ; _ .. : _.. _. _ _ __ � r � ..,. , ... _ '.. .. �� ,,.r7f ��a.. , g - . ,: ... . ,: _ .�: ., .. ....... ., , . . . . . . . ...,. . ... .._. . .. . ... .'._. ..__ .. .. _ . . _ . , , .. . _ v� ww., �,,���`( ,:.. ,-. � .��. . � ; :� ..:,_. ,�. :' .u;.:� � , .��.� . . . , .. .. � .-+r--•------s ... Yi ¢G s ¢. ... �.,-': .. .(h' l.�m;Ac�d��uuuGF 3�:��_ . ,. .. , � .� - . . . . � . . ., ��i�.�...�OP''sill5 YC'�6UEt ' � .. ., . :. , ., . . .. . . .. ... .. ..._, .. . . . . . . - - - • � � � .. .. ,_� . . . .. �� �: ... . �.. .. ._.. . . . . � , .. r . . . . . . . ._ . ,. . �� �. ... '� � . . .... . -..-. . ..,�. �. .� . � r * , .. 1�Le _ . ,. ; _ _. • (�waer� . _ .. . , ._ . �_ ... — _.__... , _.._ _-: + � E�dSP@CTOR'S Ri0'!ES . � ' . . . : ' .j _... 4 .'. . . . � . . . .,. . . � ' .�?. . ...''.. . _....,_. . .....�. .... _..-ry..�t... ' ' :. . . . . � ' ' - .'..,....... . ......, . ........ .�� .u.� . . . . , . . .� . ".�._ " . ;... . .: . .. .�. . � . , � � . :,n ,� �`.. _ .� �, . .. ; �s� , _ .. ,:.: , ,, .-;v ..�.:... . ..:r. ..: , ti, .._., _ .. .. ,_ ., ��� ���; . ; J , _, �; .._. �