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HomeMy WebLinkAbout1429A ..: ' `OV�.0 �.o-i5,'.�F•^wCt". ::..`�.!!�., ... ,iil��h � .. . W. .,�Se.. it.... r..,..:. ..�...w r,... .,.,...--. ...v...... . ....... -r..-.r.-.....�... ..,.....,.. .... .... ... . .. ,�g-.v R.,... . . �..-.a,. . .,.%.:2., , . . . . �. , . __., , •..W9RKER.S.COMP,ENSA710N DECLARATION I he�reby affilm.�that I have a certifiwte of consent to self � ansur��or�cerhficote of Wo�kers'Compensation Insuronce,or '6^6''c /� o eertitied y thereot(Sec 3800,lob C. •_Eeen Re'�-`. ./yPP,L.I.G,ATION F.OR.._,PE�iN11T - � Policy No. �$ IOCompany S'ta�e �nd . . c�W A C . . ❑Cernf�ed copy is hereby furnjshed,.,..,,..,.. . . .�7E,FS��. S,EW.AGE.DISPOa7.AL � � � 8 26 8�, i ta„�, T. FT2@IDa,gp4�r4on ' COU_f�TY QF.,LOS ANGELES,.... . . f,Bi�14DING.AND SAFETY . �Certified<o is f led wuh the tount bu�td n n. � ... PY ,Y�. 9 . -. -,.. departJ eNY'...-,...�. : .. ... . ,.. pa,e_ /n / pp ri FOR APPLICANT TO PILL 1N C9NNECTION DATA ,,,,,,,,,,,,,�,ERiIF�CATE,.QF„EXEMPTIONFROM.WORKERS' ewioinc � '�- -� �� �� � COMPENSATION INSURANCE A�'�RESS ' SiATION oEatH . . „-.v.-...�...., ..„...,....-,.._................ .. VPPER (Thia saction ne.ed not be completed if rhe work involved by ihe �txAUTti a MANHOLE fiEFERENCE LOWER perrr.ii)is.for one..hundred dollars($100)or Iess.J .� � � -�� - -� � rrreoFcor�meaion� � " � NFAREST ��e W a IENGTH FROM I,certify thm tn the p�rfo�maace of the wark for which this caoss si. ta r. c�ea P L M.l ro a.i. permi+is issued,I shall nof emploY any person in any manner __.......... __. .._. __.. .. . . . _..,....._.,.,_. . _. __ . . so os to become subjecr io the Workeri Compensotion LOWS. OWNER G.C.ND. /.r O 4'/ The Anden Groti;. CO.IMP NO JOB Np �''��.o� . ._._p. ._ , ,_ ' ..: .... �I PO .6JOX � TR1Jt,��RN'�T,NQ. , . ROADFfRM�TNO Oofg APPlicollt ADDRE55 ...... , . .. . NOTICE TO APPUCANT: If,.ofter.mvking fhi5 Gertificale Of ���Y / AfFIDAVIT WAIVER EASEMENT RKORD INSTR.NO �ATE � �nption, yo�..s,h.4uld...bocome subject to +he Workers' tEGAi..' CQVI'na 'ELNO. S1S v7� 1 pensanon prov�sions of the Labor code,you must forthwith oescaivnoN �o*No 1 HWY�OR ST.WIDENING �comply with suth provlsions or ihls permii shpll be deemed "��"��' """� . .. revoked. eio:K react S7AiE�ENCROACHMEM �� ��- .,. ...`....... . .... . .....NO�OF eLDGS PERMIi NO. , .,...,_....,_..Il�ENSED_CQNiRACTORS DECLARATION s�ze oF ior . , . Now oN tor " � ����-'�"� "�' � ' i hereby aff.irm.�hat I om licensed under provisions of Chapter u•eor ""' � ..... 9 (commencing wifh Section 7000)of Division 3 of ihe Bosi- succ�.���s '"���� �� �� �GtAR�Es ness and Profossions Code,ond my license.is in(ull force ond � � �� - �-�� - - "- ' � "" yf{@C}. � CONiR/1C10R CONNECTION CHARGE FEE ..... .. .... .. . . .. . . . ..,.....:,.. . .... . � � Li42nse Number d7d�_RR7 LIG CIa55 ��_ A�DRESS 'REi�M8UR5EMEM FEE Q Contractor y• Freeman Date 8f 26/86 ��tY � �ISIRICTNO. uROVP NWP PROCESSEDBY V , ......�.. ., . / BK PG ❑I am eaempt urtder Sec. of the L.A.Co. iicer�se No. HS �(�TOY clnss G C% � � Q Plumbin Codeand/or5ec. ofthe No � ,,.oPS.CRIPTJONOPWORK ree �" FINAI 9 . -. �a�sesewekcovtiecr,nc.o � onr lZ�t YAIIQA .ON � . .,_B..B..P._Code for tha following repson PUBLIC SE'NEB �{�86 � -' -�� - - o PTIC T.4NK,$EEFAGE OIT OR FiNp� Z _ , DOte �'S AN�-OR DRAIN:iE'.D BY �� . . � .. tqUSE SEWER CONNECTiNG TO �-��"'"��� � PftIVqiE�ISVOSAISYS�E $i(�nqture , rpNNE^ADD�TIONAL 9lCG.OR , ���� ���� . O,WNER,Bl11lDER DECLARATION wo2ic ro Nouse s�wea OV[RFLOW SEEPAGE Pli DRAINFIELO I hereby aftRm ihat I am exempr,from,if7G Con,tratlor's License ezrN.,.E55vool,ow.rweu,maNrro�E � ,I /� Law for ihe following�BOSOn(SCCIOn 7031.S,Bui5f1C55.On(I Pf0- A�1ER.NEPAIR,OR 9BANDON HIXJSE .-=� G-C�I'1' � `On3 COd2J: SEWER OR DISC05.4L SVSiEM „�„�I,as owner of the properry,or my employees wilh wages as , �� � e �1 � their sole compensption,wili do the.work.and the�structwe _is.no�,i.n)gnded o.coffered for sale(Section 7044,Business ' � `� �`5�� qnd Professions Code). OWNER'S Permif s ],Q Q = ❑I,as owner of the property,am exclusively comracting wiih ��TF�ORIZATIQN TOTAL FEE �p��!"'%�-'��" � „ „�.,t,2h50,(}COt11�OCi0l5 10 consiruct Ihe project(Section��44, i NAVE AT,iH15 OAtE A COI.TfjACi.,W�7H TH[,NEREIN NAMED CONTRACTOR 70 �C�G Y•�a'� .� Business ond.Professions COdC). C�NNEC�.,p+E ABOVE DESCRIBE�E%IStING DWELL�NG TO LHE GVBIIC SEWER � � . CONSTRUCiION LENDING AGENCY ' I hereby affvm._thoi,Ih@Ce_.is.a construcllon lending ogency SIGNEDTMIS����DAYCf 19_ ' for ihe p,er#p,rmonce..of the work for which this permir rs ow EasUnc,�N1 ��j�c� '��'`�d' z��z ,� issued(Sec.3�97,Civ.C). AODRE55 Lender i Name ���"" ���'�� � � � � _.. ..... _... . ......... . _ . . . . Lent�Er;s�A,t�dress.___....., . . . � .. . . . ,. .. . � .. . ��� I�certify fhat I have read fhis opplicotion qnd_sfate.that rhe � ,.,abpy,g,information.is correcc I agree to comply with all Couroy . � ' _..,.,qrdiRa��es,and Stote laws�equlafing Plumbing ond Sewers, . � � and hereby authorize representaiioes.of ihis Coumy ro enter . . � �. �upon t e a60�e-menfianed property for inspeclion urposeJs�.�/ - � a'�YC.� ��O � O/�(.F1/U(c . .. . . . .. � " . . ���. 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