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HomeMy WebLinkAbout1561A _ _.. �.�„� ,,x� �_�T1 ,�;;: �;�. -. -_�, - - - - WORKERS'COMPENSATION DECLARATION , , � I he e6y affirm iha( I�hove a cenificate`�of�conse�t�to, self � �� ����� , ��. �� ,�,, � � �. . , ,. , ,� � ' ��anba2o - . . .... � � msure,or a certifimte of Workers'Compensation Insurante,or . ' deertfied� ythere�f(Sec36601abC.) ceeoeiaev.siai�� � �pp��CATION FOR �PERNIIT � �� � � � � � �. Pol,cy�No; ompany S�• �U11f� �ais � � ��� ❑Certifi �opv�s ereby furnished. SEWER - SEWAGE DISPOSAL �� � � � � � ,�. � :...,..•... _ . _ .__ __. .__ Certitied copy is tiled with the county building inspection � COUNTV OF LOS ANtiELE� � BUR��IFI�ANIS SA�F�TY�����.���.,.��,'_. �'I"-'.'� �deparim�en�. � � � Date ` 'Appl`mm '"" "' FOR APPLICANT TO FILC!N CONNECTION DATA -"CERTIFI�ATE�OF EX�PT7��1'xR0%v1'�6R�EkS'�� - �� aunoiNc " --' � �COMPENSAiION�INSURANCE �-` '�� - nooaess �, � � C.--�[�� STnrroN oEPTH , ' ..,.::, , :.. .�.. ..,:. .,,,: - . .-., (Th�s section need no(be completed f ihe work�nvolved�by ihe D��� B�- �� - - - '��� ��� � mnNHo�e aeFertence UVPER --�pzrm t is for one hundred dol lors(5100)or less.) �ocnurv iowea '.-��.�.� � � ���-����+���--�-�-�^-� + -�-.��� ���� � �� � NEAREST �fyt - TYPEOFCONNECiION � LENGTHFROM � �� .� ,ertify that in�t�e�performance of�he-wo k�foi which this caOss sr. • 7;1 x . Y. CURB v.i. . ,M.i.ro a.�,,m, Ic �' permit is issued,I shall not employ ony person in any manner . "�-^ ••' ���" � , ..,...... ;;� so as to become sub"ect to the Wo kers'Compensation�awg. TEiE ANDEPt GROIJP�� ����' ��� °�� "'O' '� (�s� � CWNER CO.IMF,NO. J06 NO. , �� �[/ .., ' :.. . ;:, ... � .,:�..r^,.�� _ :�:.. � � Date S�ZO�HEfqPPlcant �e F��.E'muY.�', N�I� � - TRIIhKPERMITNO. ROADPERMI'NO. ADDRE55 � NOtiCE TO APP�ICAIV'f If,�after TQk n'���i}�s��Ce�tificate�of� �Ov.��a p�9 p L � PFFIOAVIT WAIVER EASEMENT RECORp.INSiR.NO. DATE 9 CITV T"eL.NO. �1C] V . .��^•mpuon, you should become sub�eci to the Workers' �,�A� . , . . . . � '-� ipensation pravisions of ihe Lobar rode,you must fonhwith oescRiarion ioi No. Hwv.oa sr.wioeN!Nc cumply with such provisions or �his permir shall be deemed 35754 "-�eVoked. BLOCK TRACT STAiE ENCROACHMEM ' -"�� LI�'ENSED'CONTRACTORS DECLARATION � �' � � ' � na OF BL�GS FERMIT NO. .,. SIZE OF:O' NOW OY LOT I herebq affirm�hat�l�om(icensed under pi'ov s ons�of Chapter� uSEOF ' � �- 9(<ommencing-with Section 70tl0)�of Division 3 of the Busi- swi�w�,s r�J131 1.8 �P,$• �HARGES :� fiesrand Professions Code,ond my I cense s n full force and ""' e#fect. coNrenaoa �''R�"'�L� Ci��s�. y CONNEGTION CHARGE FEE A�CRE55 8225 Beechwood: I�r• Q License Number 1�7t�$$'� � L c Class�4 . , . . 1�. aeinneuuseMeur Fee Y� / �^�,yT �7p �ISTRICi NC GROUP MAP PROCESSED BY V COnifOCfOf� lTAPTPLr'1TI� DO1B IA�C��R_r f] ��.Tv 11-4t+C�. 2JOIIIa. TEL.NO.1� GlO� Z gK PG Y � � , . . . : -',... . .,... � . I � . ❑I am.exempt under Sec of ihe L.A.Co. i cErvse No � $$ cinss L-C� o . , . �.. .. ... . � NO, �ESCRIP110N OF WORK FEE - Plumbing Code and/or Sec � � of ihe , FiNA� �V � ' HOUSE SEWER CONNEC�ING TO ' ' � JATE VALIDA ON J� .�"9 . . - . . . PUBLIC SEV9ER ; r f''� QJ N � B.��COdC t0�IhE fO��Ow h @tlSO� . SETIC TANK,$EEPAG"c Pli 04 � ` c `y '� .. '•�:�'�. . . '� ''':�� '.':�. PITSANUiORDRAINFIEID FIN , �.. . �.. ; . Al n � _ � ' ' Dafe HpUSE SEWER CONNECTING TO ��"�� '� '-"' a� C �- .. . :. • ' P�iVATE DISP SAL SVSTEM 1\. $9nafUIE � �� � � CON�JECi ADOITIONAL BLDG.bA - ' - - ► �� ��' � ' OWNERBUICbER'DF�LARA1TbN " �- ���� woercTOHouseseweR OVERfL06V SEEPAGE PIT,DRAINFIEID . I hereby affirm�hat�l om exempt from ihe CoMractor's lice se ������-- exTN,ce55700�,�Rvweu,MaNNae � Cla�w for the following reason(Secton 7031.5�BJi3nE33 Ond Pro- SEWEROR 0�15 OSABS SDOrN HOUSE � ' i `�5� y ions Code): . ,�I,as owner of rlie property,or my employees wiih wages�os v?� � e 'D ; i� . � ��heir sole compensotion,will do ihe work qnd the str�crure � � ' ' �is not�in1e"nded or offared for sale(Setfion 7044,'Business �� � -�c•i i,�G , .- '�and�Professions,Code). � � OWNER�$ Permit S 1 �j� . ❑I,as owner of the property,am exdusi�ely contracting with AUTHORIZATION TOTAL FEE ` ' ..� '`:�L:v . licensed<ontroctors to construct ihe projeci(Section 7044,'���- i Have nt tH.s onre a cotireticr wiiv ri+e HeaeiN Nnnn[o coNrrtr+c�oe�0 4 ' B�uSineSS OnCJ PrOf955i0n5 CoCIeJ. CONNECi THE ABOVF�ESCRIBED EkiSTING�WEILING TO THE aJeLIC SEJJER, V r.i:�:^�6 ���` �6NS?ffUCTION�lENDiNG�AGEN�Y '"� �� ��� ► - I hereby af4irm that ihere �s a cons�ucfion lending agenty SIGNE�THIS � pA�OF A�g — ,986 �� for the performance of the work for which this�permii IS �� OWYEROR M 11 A{�D p y�/� . � ssued(Sec 3OJJ,Civ.C.�. O`h'NERS AGENi nooaess �F� B echwood �r.y E�.tFi OII11 Lender's Name . . . . . . . .,� _; ,..... . . ., ... . . . . . .. . . . . . _ . .� , . .._ ,,... ;� ; �-... ..: ..,..- .:...�,:,. ,�::..: ...:.. . ... . . . ,- . . . .- . ....�.. ,..:: _..� . , . .. . ._ . . . .. . . .d� Lende s Add ess _ � ; � � � ' ' <.. , ._,._� . _. .,........._ . .. .. ... ..,� ,._,.. ..,.. .. ,..,.... ... ... . .., ..,. .> . . . . , ... ... .._ .. . . . . . .�.. . ,. , , ., .....'. .. . .... ,;.,,, I ceififp�tFiot I fiave���reod ihis pppl coiion and state that the� � � � � �-� � � above information is correcl.I agree to comply with oll County - -�o�dinances and Slote laws regu�ating Plumbing and Sewers, `�a�n,d�hereby authorize�representorives of this County to enter , -'upan e abov ntioned property for inspectio purposes. € -�������er'��,� �� $ignature of Permittee Date SEE REVERSE FOR ERPLANATORY LANGUAGE .,. � .'.. _:.�.... :.. ... ...:�. . �.�„ .. ;�o�.i,:. ...:,.,.':.�:...�,�..,.. .' �_ ........ ., , ,. . .._ � ..._.,. ....._. .. .. . _ . . . �. . , , ,.�:..:� ;:a:t :.,... ..a., w.:i,�,.,.��u ",..r,?•, .. ... . ... .. .... . . .... . . ,. � . . . ' ' : . " � . ' - . ' ... , . ...� : . . ,�..�r::.:x��:c++i:.'�w�:�.�;a..e`.�c:..c��-•-.,�. . .. . . .. . . � _. _.. . .. .. .. , . .. : � iINSPEGYOR''s wos�f . . ��I�R��7TLD�r.I3 L1lEC�.A]R�T�L3�3 ,.. ,... ... , .srt�. ,;t, s � :t.• APPROVALS� onTe x WSGECfOR'SSIGNA7URE _____ I}t�:Y�lyR.ifilkltQPt$YT8s3�xYEt]fEfi'(jT.Yf}iC+CpI2fYSCCOR�S . "�'—"-- — Licease Law for`tue�18owiug xeason j5erbiaia 7�31.5, � NEVY>IOUSF.SEWER - . . Boe.ciness canut'3Yrufe.ezious CodeJ:Aay crs�yr ar couzty - ... ... . _ .... .. _ .. mNNecr aoe�noruu � r�_��--- � _ wbie5 t81f%iCE.B 2 J)6Tf]{42$O tOY38Y9:6Cdr olt�r,mx�rror�e, - .:,. BUIIDING OR WORK ' ... �gryyO�iS�I.Of YE87A%P,aTqj�SdD'YCh{PE��bPEOf'Y!:SfS SSS!lOAiQ� ' '% SEMIC TANK,SEEP,AITlS) � ' ' -"- - "" AND/ORDRAMFIELD ' CSSP YBIfMiYBS t.be a�plrcrme}`ar sucb parnsst to fcle a c�sroo�!] oRvweu❑ - ssgxed szatem�us sbae bs ac ikce�s..d pura�aae ta sbe �provistovos oj ikrz:Co�=raeaor's Lrceu.se Zas�r fCZ�aptsr 9 .�:.�, Ath�,Revatx,sewea at � - .-'- _--.-- _ - fcn+iaameauimag wet{��Sactioa 700�J,i o,f dh"vi�-iota 3 vf tFse ' SEWAGE DISPOSAL SYSTEh: ' - ' ? � barssttr.es�u»d P>-afi�siotis�ade%vr 2hat be zs e.zernpt ,: _��_ � £ . DISCONNECT PLUCr AND � ! � -• � ` tb rovn aacri Eire 7�ars.c for zJse adle d x.xer,sjitfon.�l.xy �,. ABANDON HOUSE SEWfR �_, .. , .. . � . . + .� . . riiodatdoyx�rsf S�crsa�7�l$Y.S�y"assy u��+e"et¢rat for ag5ernis� BACKFILL SEPTIC TANKS❑ '—" . . ' ' . . . -. S#F1'EC�$�98& 1r a�ct�a r:icS1 a�aa.$t o naz mowe Ebatt -.'.-:. SEEP,PIT 5)❑ CESSPOIXS❑ _ . ._ 1 . .' .X3 .V �• _ . .. . . �:. „' ..:"«. . ._. . ... ... �,�,.�.�.. �,. ...... . . _. . . ��:�i12NV�L'$dtPlOd�°�yf3!),b.: . .. . ,.�..�.. . , .. ... , . . . ' . _,.... ._. . . , _ ,. ,.-. �_��_ as ahe oevaaex the pru�sacq;✓switt da xh�warnc,aad - � �� � . �,°.: � � the strucixtte'ss�aY ivtendee!�e offeged�esx sale. ,. . .w.:.. ,,.. ...<,. .,-. �: . � .'..:\ ..\ . :..�.. .� . . . ;.: r ... , /Sec. 764�,�u�anesr�hd�aofa,.:sosas L'odee �'_bn- �:. , - - � ,� � , ,. . _.. _..,_._.... ,. . �;:., .r..:,.,. . ......._ - � 3w^'s I.dees�.s�e Zam dae.r ena_ 1N td�ass as...�oj ,,,;, .�,.. y$? :.� �.� . ... . . . . .. . .. . . . ..--.'. . ,��,.:r` �W. �'-�' �roperty'iuEro bnilrXs or inepvvice>tbereoao.asid wbo do� �; . .. . .. .. � " ._ .. _.. _ ..,_'.. ._ _.. . . - _ ........: . . sucb 9vork btesss�lf�roa�ided td�at xuc&4rxpranerxewRs , . . , , . . . �:.,. �;:..... .__. _. .. .. ... .. . .. .._ _ ___. ..� . �.. �� . :� are'�o`s 3siden�de�d ar uffecsd for saee.If liower�r, S�e ;..,. . .' . _. ... . _. . .... ._ .. ..._ �, a" ��i` �,.;;, - .: . �. _ ......,,.. ldi»��br�lxspror� .asia �,S�ea� ,,�. ..... . .., .� � , � .� � , .. .,. . ... � � �rapYe EosA, �b awxer-FieasF�er wsYl$bave ehe � :.... ,._ . ... . . . 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