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HomeMy WebLinkAbout1560A WORKERS'COMPENSATION DECLARATION I hereby affirm fhat I have o�certificate-�of consent'to self � � . � - � � . ns re or a cerLficale of Workers'Compensation Ins�rance,or ]6A6n2D . ac�rtfedc �� Sec.380��a.�,�d C�E0C6;REV.B/BI) APPLlCATiON�FOR PERMIT �� ��-� �� � � ��� � ' Pol ty Nq� � ompany . .�s /+ yy �jy��`y� . L�'Certifie copy is erebY fornished. �EWER • ��WAV� V��f VJ/"►.L�_.,.,. _.... .._ ..:.,.., . ,.�........_ .. . . ..._,.......,..._,-._...........„......._. . .._ . -. �Certified copy is filed with�he mumy building inspec�ion COUNTY OF LOS ANGELES .-,� -, BCII'LbING AND�$XPETY-� ''depariment. . . . " o6te fR��pplicant � �+�.@gyg�� POR APPLICANT TO FILL IN CONNECTION DATA r .'�CERTIFICATE OF EXEN1PYPdl�KROhA��WORY�ERS' �-, � � � a��io;N� _ COMPENSATION INSURAFJCE �� ' nooa[ss �� ' / � �-e—��� srnnoN o[mr+. , . (This secTon need not�be compTefed if the�work involved by ihe ���AiiTy Dz,(� � ]3� n,w!vHO�e ReFeaeNce uavek LOWER ' , permit is for one hund ed dollars($100)or�ess.) . , "' ' � ' �' '•� "'- � ' ���� . �.-.. NEAREST `,, - iVPEOFCONNERION ��� �ryGiHFROM � �I�certify ihai n�ihe performance of ihe work�for which fhis caosssr. v. cuza ai rn.i roa.�. "'" �rmit is issued I shall not em lo an '� _ p p y y person n any manner p C NO. , �� � sb as fo become subject ro the Workers'Compensation LpwS. OWNER � � � � CO.IMP.NO. ' ' JOB NO�- ... ... . .::�,. .�.. , � HODRE55 TRUNK PERM!T NO. RM�PERMIT NO. � Dote�� ��Appl caN���. � � � �: �IL P� B x 2 �'�� � AFFIpAVIT VJAIVER EASEMENT RECORD.INSTR.NO. DATE �� � NOTICE��TO APPIICANT��If, �afier��making��thii��Certificafe of--� ` �-'-� �,ry .�18 6 Covina rE�yo _ � .,,rc"'�mption, yo�� shauld betome su6ject to ihe Workers' teGat . ipensation provisions of ihe Labor code,yoo must fonhwith . cescaivnoH LOTNO. HWY.O65T.WI�ENING cumply with such provisions or this permit shall be deemed 35754� ' � � 'ievdked. a�ocK TRqCT STATEENCROACHMENi � PERMIT NO. �� �`�� LICENSEp CONTRACTORS�ECLARATION'� � � r+o,oF e�ocs - � � '"" SIZE OF LOT NO�N ON LOT ��' ' ' ' � I h`ereby�aff gihat�I om I censed j nde provisions�of Chapter use OF S`131��,Q �,@$. � 9 commenc n ith Seci on-7000 of� ision 3 of the Busi- eunoiNos CNnRGes ' � ness�ond Professions Code,and my license is in fuli for<e and 'p ��" CTfCCf. �7 !7 , �y COM1iRACi0�2 �j��j,�j�j� � :ONNECiION CHARGE FEE 4 l tense Number 4 f Q�gS pi�,��a55 �+� ADDRE55 �`2 REIMBURSEMEN'FEE o Contractory• Freeman���po,e ��8/20/86 ��.,�Al�a 1l0��.• TEi.N0.�1 �o� 2 DiSTRICTNO GROUP MAo PROCESSEDBV v .��. _�.. <�. . . . : aK w Z . L_i�I am exempt under Set � of the LA.Co. � ucenise NO. � " ¢� �j$ c nss �'� o ^+c DESCRIPTION OF WORK � �EE�" y PlumbingCodeand/or5ea �� �� -� ����ofihe� � �� � FiNAi � - �� � � '' ' HOUSE SEWER GONNECT�NG i0 �J �ATE / PUBLIC$EWER � l( O I��zb��` . B &�p.Code for�ihe following reasan �� � � ,� � N Z : . . SE�TIC TANK,SEEPAGE PIT OR FINAI " ' P1T5 AND!OR DRAMFIELD �^ ���8� - HO�SE SEVIER CONNECTING 10 BY r . . .. . � ' �' . PR�VATE�ISPOSAL SVSTEM � . S ynafU e GONNECT ADOiTIONAL BI�G bR ' � � - �`- �� OWNER B[11LDERbECLARAI'IDN � � � �� woaK To House sewEa'�� ' �' �hereby affvm thai�I am exempt f om the�Contracto s�L'ice se���-��� �iNF��essPoo Goevvr�RAinniv�HO�E - - � Law for the following IEP50��SBC�OfI 7O3I.S,BUI5YIB55 OII(J P�O- Al7ER,REPAIR OR ABANDON HOUSE ' � " f�`iOhSCo[Je�: SEWEROR015POSAL5YSTElJ� � '" _ -- ,_ � �o Q�r, ,� I,os owner of ihe properry,or my employees�wifh wage's as , ��their sole compensation,will do ihe work ond Ihe struct�re� i;`== R+ �� i (; 'is nof intended or offered tor sale(Section 7044,Business � �andPiofessio�s Code). OWNER'S Permii g 1,t) � , a,m�%.�f� � . . ❑I,as owner of fhe property,am exdusively contrpding with �UTHORIZATION TOTAL FE@ _ _ " �iCEnSep�contractors to consiruct ihe projecl(Section 7�44,' I FIAVE Ai iNiS DATE A COIJTRACT VJITH THE HEREW'NARhED CONTRACTOR TO � � �l �'"���'� .,. ... BUSi�E55 a�CJ PfOFC55 0�5 COdE�. CONNECT THE ABbVE OESCRIBEO E%ISTING�WEILING TO TNE OUBLIC SEWER. _ `,' (� _ _ Y�L%'Y"'V V - � '�"�� CONSTRUCT16N`CENDMG AGEfJCY � �"' �� � / �'�e� o , '. � I hereby�a4firm that fhere s a consh cf'on lending�agency SIGNEOTHIS v D F 'A""� �79 V . for ihe pe formance of rhe work for �Fiich �his permit is OWNEROR �q �g OWNERS AGEM . � issued(Sec 3097 Civ.C) � - �� �`�'���'p-�'6�'d'�" s77�:j.e�i.i�is Offi'd ..,...:,. .. . - �_�.- � nooeess � '�Lender's Name � � �� � � �; . . . .. . ., ,: _:. � .,. .,,, .. � ��. . . . . . . .:.. ..,..... .�..r.. .:.. t-:,;., ; �....�; , :. .� ,� ... . . .��...:� �. . _ .. �. .. �. .:.,..,_,. , �..... . . . , � . . � . .,.... . ... . . . Lender's'Eiddress � . . .._ ... . ..: ..... :. . ��.._ '.,� �. . .. .. . . , . . . � I certiiy that I have read���h�is application and state that the � � � � � � . above information is correct�I agree to comply with oll County ��� �� � � � � ordinances and�Stote laws regulating Plum6ing and Sewers, � .. � and hereby authorize representatives of this Counry to enter � u��`i na�f Per�������� r inspecfion rpos 5. � e a ov�ntioned o ert fo� ��� g� - P� P Y J r 9 C'! E � g Date �SEE'REVEk5EF6R�E�PCANATORY'LANGUAGE �� ��� � �'��� �- � - - "- �" -" - _. . --�------�--�__.s_.,�.,� � ... � :: r; 4 � ;- � :.� ��svEcraas wrfr�,s : E)��i-�HJIL�3�I�I9�C�Ai�A�'E�l� ;, � � R�PR�VALS DATE INSPECTON5 51GNATURE • � .___��R�R I SIEf2�J 8YE9Yffl YjY&i d 3Ei)F1�I�z fi�bra.ti4e Cantrsceor's . . .. d:ieense Laee#or gi:e 4o1[owi�xg:eason(Sxtion 7G31.5, NkW HQUSf SEWER � . 8asiwess a�i Frafes..csaza Codel•'Atty+.d3y ar socc�Ey . CONNECT A��ITIONAL I . ---.�.—'�_4j—.. _� 'WbtCL PBQ9R8914F��ierxnie m snvzsfrura,ott.,�-unps�nus. ."'".. BUILDING OR WORK semolis s. �a;3rzar�ssy s:c�zctras�e,:y9�rsq�r�So s'Ss isaxenxce, ' -a+ '" �. ........._..._. ... �', . � ".�PTIC TANK,SFEP.PIT(5) ... �SCi�:.:..,u rBS sD.'s�°�.._..Ttsasae or,^mc� - AND/OR DRAINFIEID ` . . . 1'F� �j) �'�:µ.. QdsY7PfE tC fBle N cessPcoi O a�vweu❑ � . . , . . swgusd staae�newt t8at�e ds Yla�exsed purs�:ant 8o tbe . . proviafotac of tb�z£x»a�::esPoz's Lisense:.aw jC7wjiser 9 es '2 ?1TER,REPAiR,SeWER OR — . . ' ' ��. lCOA�W:E9M.Y�'^..v£t1s SecEeo»-7DOOJ af Dir�isEora 3 of s6c " SEWAGEDISPOS/+15Y5TFf�,t � ' ' Bas¢ttesi unc!l�rofasseoias�Codej or t�iat he es ezs�nspa '�': OISCONNECi PLUG AND � ` ' � ' � tberefrom nnd tbe basa:far sh:alJeged euern}:tdmx.t$ny '..... ABAN�ONF�USESEWER .� .. �... �. .,., ..... . ...._.. . � BACKFILLSE7TIGTANKS❑ ..�.Y/8016Ef0£E3..t.SECSftY.a]�J�Y.S�'J�39tg+w'��/IfCRNL�09'd,�@fAD85G �'.., SEEP,PIT{SI❑ CFSSpDOL$L�. ' _ S46SfBC$$�8 5f3dl:fCAWB✓$6 m'GN1lii�l2qIXSE'}!C;'60$9N09Y.'��169d .'.' ..:�,.. . . ,,.. y ..,.: :i ., .......w_ ...._....._ .�r.+�.,.-.� v�,r+�» _...., � ... ..._....,._� ''3y��IdHl�6'E�I�Od�6Ta'I�J�Q�i.: '..' .. . .. .. ., .� - ;., � '. .. ..� ...-. . . � .� ...�.�• J . .._. ��•1.�..• " -. LJ�,as t�e awmer aY t6e Prope seili du Yk:e wosk,an�F � .>: "� �� , . . . �:;� ...� - • '.. � dhe struct�m is nart inYeoded'aR o�ered 4oa sale. � .. , ,. . . . � �' ;.,-. :,.:.� � � � , , ...... . . .. . :.:.... .. . .. ..... .._ . ..�--..... � .. ....:. .�_.. .. :�-. �. ��-- /Sze. 7D;�4, Bu34nssr�-3sw aroJessioszc Code; Z7'"'z�_ , � .,.:. . :�"-".� , _ .. � 'F'x'¢"a'tor's Lice�s¢Lzw does aeot Ty aa,srz m. r of _._ .;..,,. .. ...� . ..��. . .. - . ..... �.i.�4 .� .... ..,grrnparty s+>bo budLds.s.»��aa tbe�eora>na�who do�s .,.... ,. .._ .,.. _ .._ . ......... .. -. - ..�..-, s� . . ..� ..... ...::". .. .. .. .....'. _.-se:c wark b:mself}Iseav'� Ehat sucd iacpraves�aents �.,- ....... . .. ... . . .. . .. .. . _. .. ...' :.. �. , . . .. . . ,.,: .. . � . ,. ars noB�$r6ei^de3 0:offerzd.�aw suea.Ij,boaveuar, a�id ` ����..... . .. __._.. ...... . __ ......_... . . ._, , , � � �a.�s' �..i��N i-� �..�`�� •:�..- LtsdldeiqQ��ar�Sssc¢ravecxiewt�as soX3��waLbea aRe yersr�f ,... -.. . . . 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