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HomeMy WebLinkAbout1565A _.. .,. , _,:_. . _ , . - . ... �:.. :. ,.. , � �::- � ,. _..�,.. ,r.�:;� .��-..� . :.,. . , . , .w..�� ..,,,::>�..��.�.� _,.::"i WORKERS'COMPENSATION DECIARATION„ y � � . � � I hereby affirm �hat I have a cerfificate of consent to self.. � .. ."". .''...,,..." _ ....•."" .�•'.:.... . .�.-..•--•_.��,. .�..<., ,._.._ ,... ..:...:..:.. .. .- ��jI ' .... � . ._..:. ...�.:...,-_ . ...:..:_. ,:.,: : ...:_ ::2S nsure,or p certifimte of Worke s Compensation�lnsorance,�or"�� " -� �ea6 20 ' � � - � , �o��Y`'���Cosmpan8��'���'F�Aa ��B,R"B,8" qppLICATI�N. FOR PERMIT ❑ce.,�,� � �5 erehy furnished. SEWER - SEWAGE DISPOSAL . _ �Ce rfed copy is flled with the county building inspeclion COl3NTY OF LOS ANGELE$ BUILDING AND SAFETY .,w_.� . dep tmen. . . .. ,_.. . ... .. . . Date S �LO S6 qppl cont `1' I'Y'e2D13ri FOR APPLICANT,Tt)FILL_IN, `" CONNECTION DATA , . CEkTIFICP,T�OF EXEN1ffilON FROM�JORKERS aui.oiNc ,.? ,�y/r��":! � � ST,�T�pN � oEPTH�-�� "—'-...--�..•.�.�,-..„ ermit is for one�u dPeN�SA�'110�5 I$,SO RANCE � � �� ADDRE55 V V��r_y A,F � P his sect on need not be camplet(d if t je wo k nyolved by ihe �� " "'- '""�'��"' '�""-'-^ - - � ucoea LOCALIiV � - � �- I'MNHq.E REFERFM10E � LOWER ... Of IESS.) NeAREST . � .. ...,,�.,.._.....,... ' '!9 c�' '� TVGE pF CONNECTION' '. LEfWiTH�FF�O�s•••.•;"•�.c..:v.-.-. '� I cenify-iFiat in the performance of ihe�work for which this cRoss sr LJ ;.A.l Y. CURB P.L M.L.TO v.L. � �.' permit is issued,I sholl not employ ony person in any manner _ ..�:.-: .-�..,.,., . ... , P . . ,..... ._. .._.. _.., .._......._,,..._. ��,:. � .. nsdiion LawS. owNEa .��I,'�' rx �J� . .., co.ima.rvo. �,. � ooe o�..,.Y..a�...,.,,..... So os 10 6eco e s b ect m the Wo keie'Com e �..:. . .. ., .. . . ,. . , .' � . . . vai� . .. . n_(_] ,.�.r...�.<.,..,.w...:.., DO�E � APPIiCOflf �.�•. �. '�.�'� .. AWRES$ �Q BOX. 33LJJ�..•.� . � ' iRUNKPERMITNO. ��'..�. ROADPERMITNO .,��..,'_rv�..-:.Y�LLM � �� � � � '�""'"��"�°"""`""'"""'"""`� AFFI�AVIT WANER EASEMENT RECORD.INSiR.NO �ATE NOTICE 7D'APPLICANT�w If,�after�making�ihis Certificate of �� ' ' 818 6 ,.. ��,Y Govina TE�No. _ �.,j•^�trpt on, you should��become su6jeci to ihe Workers' iE�a� . � � . ' . . '. _., .'_ .. ' rovisions of(he Laboi code, oo most fonhwith � . .. .. _ _,_ ., , lpCnSO�ion() ._ y DESCRIPTION � . LOTNO. HWV.ORST WIDENING ' wmply with such provisions or this permit sholl be deemed � � ����- ,--�� �-.-�- ...-...._..,.., . .. ' �revoked. a�oa TRAGT ST�iE ENCROACHMENT �� ��� -'"�����'"""`�" ' """'"""'"^""` . r'� �' UCENSED tONTitAtTORS�DECLAkATION � � � �- � ��-�o;"tSK s1�cS � ` � � "." ' ceunniT No. • ,�,�. . .,--,:..., s�zeoFior vowor��or . ..... . .......�_._,..._...,...._..,. I hereby affirm�that I am licensed und.er�provisrons of Chopier�'� uSEo= '- ..^--. .. -.-� ,�-., ,- 4(<ommencing w�th Section 7000)of Divison 3 of the Busi- euaoin�s sing• R8S♦ � .�A.���,„_.,,.,,,,,,..,„,.,,w„ ri ...�,�.,,....:�.,... �. ness ond Professions Code,and my license s in full force and FR�a,�� lr��sl � � � ������ ������� , B{feCt. �� � � � � " ' ' CONTRACTOR � CONNEC�ION CNARGE FEE a � }� ....._..�.,,..,,..�.,-................-,..-......H.:.e license Number��4887 L c Class �,�Q� � � �-� y ' � -�`<�' � � � � o . AWRE55 S2Z� i7EeG31WOl�� lJt- REIMBJRSEMENTFEE ,. ,., ....,....v.....,.. .,..�„ _...w..:..n..,.: �oltllpCtOf �.�Freemar�,a�� � 8/20�86 ^'./. DISTR;RNO. GROUP 'MAp"'-"""" PROCESSEDBY ' V . . '. . . . ,..... .,.,...-. ..,.� CIiY 11.L 4a. �ffic� TEl.NO $ � . ..;:, . . . '� STATE . - . . .. . . _ ...,.. 7Ar5 ry OA..,.....�...., e BK PG Z ❑ I am exempt under SeC. �of fhe L A Co. �� � �:�NSE NO. 4 i Yo8! Rn55 Q3ry� GG O � ��� � ' ��� - vo DESCRIPTfON OF WORK �"� iEE ' . �. : . .,......� ..........:... FIM1AI . , ... ,�..' V Plumbing Code and/or Sec �" of the� � "' "" '�' '-" HOUSE SEINER CONNECfiN�i0 �' " " � ' ��B.&�P.Code for the.following raoson '� � -- �� aueuc sewea � - �7 00 oA'E 1�,��17� VALIDATION N SEPiIC'TANN SEEVAGE PiT OR �""" � � � � � � DO12 � ...::. .. . ..�'. '� �' PITSAND%ORDRAINCIELD fINAL �• ..' Z -. ..-.�_. . ..... _ . . ... .._.............. 9'! .. .. .. .. �...� ... >.,...... ,......,< �.�..w,•.xr..,..,,�:".+ 'HCUS[SEwER CONNEC?ING TO... .� � � -� . ��. ' � GRIVArE DISPOSAL SVSTEM " -' " $i9na}u g � ' CONYF�7 ADDITIONAL BLDG.OR '� ''� - ' - � "�� � � OWNER-BUILDER DEtIARATIOh�` "V" "'""'" - "v�ouK�o House sewea , - I he�eby a{f fm�htlt I of11 E%Etl'1P1{fORt fhC COnt ocfor'S L CEnSe � ' 'JVERGIOW SEECAGE PIT,DRkINFIEtD' - ' ' "-' EX'N. CESSP60l,DFVWEtL,MANHOIE _� � , ` . law for ihe follow ng reason(Secton 7031.5,Buisness ond Pro- �tteR kEaaiR Oa nnalloorv r�buse '��" � -'-' ��� i .,6..;FI :F"°�+ions CodeJ: ` � sewea oa oisrosni svsrenn . ...................... - ,_i I,as owneFof ihe property,or my employees with wdges as �. ' ° " ' � i. , ;their sole compensalion,will do the work aqd the str�tture, "'� ' "" � f 9 2,���. .is not intended or offered for sole(Section,7044;Businesi - � �arid Professions Code).- � � OWNER'S PermiT 5 .P. p Y . Y .. . 9 . . 70TAL FEE � .. -� �-%C?� ❑I,as owner of the ro ert,am exdusivel contrac�in wiiFi AU�HOIIiZATI�N �� � 'licensed coniractore to const[u5(fhe projeci(Sedion 7044, �HqVE qT Tp:s oqTE a CONTRACT w�th THF HEBE�MNAMEo�cONTaacr 2 to ;j j,�CC.-�(� , 'BUanC55 and P ofe55 Ons,CocIC). CONNECT THE/BCiVE OESCR�9ED�EXISTINC 7WElLIN'G 70 TNE PV6I:CSEWER.'� � � � CONSTRUCTION LENDING AGENCY � � � '" ""'�'���"'"� � ��� I�he eby offvm �ho �he e is a consfrucfion (e�ding agenry � SIGNED 7H15_+A��A OF�u — �1986 ► for ihe pe formonce of the ork for wh ch this�permit is ov"NER oR ' issued.(Sec 3097,C v C) � owneas,aGEn� .y Lender'sName ' � ' "' � -.�� � aooeEss - a ZOIIi3 � 2� @2G. W00 �].' . . . ......� ..�..:r .v..y.. H.»rx."t+�r ��,.as �'' t � Lender's�Address �. . : �:. .��.�. .,-.:� :�-.:. :.., ,��<:,,:,� ..x�e,y �...:..- �;, ,,.:,:, ,.�.:� .. ... ,.. . . . I certify that I have reod this applimfion and�stat�tF�al ihe..'.. . . .. ' ... . .-., .'."'-:,'� .. .. �..�� . ,-. ,.._ .....:. .. .. . ' . . .. .. .. ����� � �. ,: � ...,...., ..... � a6ovB informafion is correcl.1 agree to mmpiy with oll Caunfy �� � ���� � "�� � � �� �- - �- � � - � � � � �ordinances ond Siate.laws regulating Plumbing ond Sewers, � � and hereby outhorize represenrotives of ihis Couniy ro enter � � � -� --� - � . . ' - � � u n�he above- entianed properry for inspecli-�oses. � . I '��� �. � ignature of Permittee Dote SEE REVERSE FOR EXPLANATpRY LANGUAGE � - .. : . . ... . . .. .. . . . . . . . . . . .. . . . . . � .4 ' �. . . .... ....:.. . . _ . � . . '{�'.. K r' "• !. Z :":: .T; .'' :�_ -Y. ' ON��'�oR�S{V�.T�.e _.... , Vc . ..... �yy���p�j�1Y4�"itl _ _}�� .�wn�..+«w�.Y..a. v..+.n.�.. .. . .. . . , ...'yr��1tY➢iliLlJ�.t\&J �•s A?Y�tl - a��R�'�i�<� DATE ' INSPECTOR'S SIGNATUkE _ _ ._...__ _..�t1�FC�%}'St�][Ii4 tSf2k E 2D1 Cl(Et6.yJY�YSP18 TVP Y`O@flY3C•bl�5 � � � ticetsee Law for:he 4r51Sowissg reasa�dSerfBa�:7931.5', NEW HOUSE SEVhR � � � ' �.,,..�... Business artd Pwafessuons CvePs% Ar.y cFay oe roureay cparaecr nooir�oNa� . . . rvbic,o s�eqquires a�ermi:to rnzstrract,.oltea;irn¢rove; eunmN�ort woaK ...... .demo&sb:-ar re73tgo-��ty strssctuv�;�r.'to'�¢ts sssaanre. $EPi1CTANK,SEEP,?R(5� oko mguires ahm cpgdicaxa for such permig so fete n �'"' AND/O12 DRAMFlflD � CE5590�L(] DRYWEIL . . . . . . ..._ Si�id¢O1 3'IG18;tiBPb$+E�I6$3!C zs:%CRNSBfa=.ZiY538�dS YO I�i4 O provisior..�a�'�s Contr.uiat•'s L'uens¢Law(Cbapter 9 - -�, ALTER,REPAIR,SEWER Oa � . �to9!{9li8piYP1j�ZUl$IS S9L19091 700GJ af�23ivfsron J nf tbe " SEVlAGE OISPOSpI SYSTFM ... . . - $�f4ipS'nsed Profassions God'ej or abas,`se as rxerrapt "x �' . �,, o�smuNEcr rw�ANo � � � '� �� _ eFiePefrnsr;��+acff t6e bw+s for?�'is¢Fleged ercem:ptioa.A�ay : ...- ABANDONNOUSESEWEk -.. .-�.. .. .,<..�.,. snaeiu sETic Tnnus❑ . .. r�toludeon cy`�'er!ian 7031.5 dsy mrey�piixtt��ars perndt �.. .. SEEP,PIT 5)❑ GE55VOO15❑ ' ' ' .. .,. 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