Loading...
HomeMy WebLinkAbout1562A WORKERS'COMPENSATION DECIARATION I hereby affirm that I have a cer�ificote of consent to self � � insuFe,or a certificare of Workers'Compensation Insorance,or ]bA6a2D ' ' CE BOB!REV.6/Hl l . .. . .�-,... ^ . ..'... - a ccnified co the of(Sec.�3800-�ab C � � � ' � � � ... Policy No. Compony s�. �na .�,, APPLICATIOi� FOR���R�GI�T..._.... ..M_r._........�_�.__.__,_....,._ . �� y❑—�Certifie ,copy is ereby Fomished. SEWER� -��EWAGE��D�13`P�S�'►L � ' �.- 4J Certified co is filed with the tount buildin � . � � ��'�-�'� ��- �' � � py PP y g ins ecrion FOR APPL CAN OFOLOL`A�NGELES BU�1.��CONN CSAFETY " P de riment oa� 20 86 n i oo�+ T Freeman - -._. .._..__ .__._. '�CERYIFIC7{7E'OF E)(ElviPTION FRdfv1\N6RK�R�' - - TION DATi4 � ' .,,. , ... , euuoiNc ..�, .:.; COi1APENSATION INSURANCE ��"� Aooeess _ sTnnoN , oevrH - (This section need nol be completed if ihe woik imolved by fhe �ocAUTY DIA ]��, nwNno�e aeFexeNce �PPER pe�mit'is for one hundred dollars($100)or less.) iowea y � �performance�of fhe�work�for wnich ih�is hEAREsr - rrPeoFmNNecrioN � -i�cerrif� ihoi in the caoss sT. v. , cuee e�. MNG o vR� " permit is issued,I shall not employ ony person in ony manner P.C.NO, so as to 6ecome subject to the Workers'Compensation Lows. , owNER ,��� �j,R�'� CO.IMP.NO. JOB NO. Q �� " ,.��' �.-.'...:. �.� .. � . '� � ��� TkUNK PERMIT NO. ROAp PERMIi NO. Date -. ...APP�I cant._ .... . .::..�.: ...... ., .. _� . '� aDOREss . .'Z . � � N�TICE�70 APPLICAN7 wf after moking�-rhs�Ce"tifi<aie o{ � ��v�na ��,8/(��j`7�9G,dl AFiIDAV1T WAIVER EASEMENT RECORD.INSTR.NO DATE CIiV , TEL.NO `t �:s�impfion, you -should��become subject to the Workers' �ECAi � . 7pensation provis�ons of�he Labor code,you must forthwith oesceivr;on: ior No. + Nwv.oe sT.w�oetiw� ,comply�wi(h such provisions or ihis permit shall be deemed . . �IEVOkC(�. BLOCK iRAC7 35254 5?A7E ENCROACHMENT " � ' •, ��:.:. ...�:. . .. , �„, � ' .. NO.OF BLDGS � PERMIT NO. � i .� ` LICENSED CONTRAC70R5 bECLAiYA?Y07�"i"'""��� ��� SIZE O'LOT NOW ON lOT I�ie eby affi m iFia�I am licensed under�proJ s ons of Chopfer use OF ; 9(commencing with Sectian 7000)of Drvision 3 of the Busi- euaow�5 .S1Y1 RSS• CHARGES ����ness`ond Professions Code,and my license is in f�ll force and . '- fff¢Ct � /�1 �pNTRACTOR � O� CONNECTiON CHARGE FEE �, L cense Number 4rI4E3S'I LIC C�a55 V��� ADDRE55 .{. 8225 ��eechwooii br. REIMB�RSEMEN7 FEE � �OhtYOCfOY T�.�'Freeiii�,e ������`8/20/86 CITY��+a I;oma. ,E�.No.714 �984-4429 DISTRICT NO. GROUP MAP PRO:ESSED 9Y . ,� ...'.., . : '. ..... � ., .. . .. .:'. : . .. .. A�J � p A } ( BK PG � .� � I am exempt under Sec of the L.A Co. Si ENSE NO " y�(�HV� cLn55 C 3Y f o � � '- " � � � �o. DESCRIPTION OF WORK PEE ' Plumbinq Code and/or Se�.' ' � �� of ihe ��, „ , FlNat � � ' ' " ' - - �'' �' �' ��- � HOUSE SEWER CONNECTINCa TO " ' " ' I Q OATE /'���,�O� VALIDATION 1 � PUBUC SEWER Q ' �B.&P.�Code for_ihe following reason � � � � �� �- , � ��-, �. � SEFTIC TqNK,SEEPAuE P�i OR . �- : � . '.. .'. '•,... .-.. PITS AND!OR�R411VFIELD. . . BYAL ''� � �� '' - DOfB NOUSE SEWER CONftiEC71NC,TO"' �"-��' �'�" ' �' ' '� ' ' � -� ' vR VA?c DIS�OSAC SYST N '.. � . . . ,. . $19Y1ptU E CONhECi ADOITIONAL BLDG,OR � '�" , � ���'� �OV✓ISER tlUi�bER 6ECLAkATION � � � ���� � woRK To House seweR' ' � ' ' �'' ' � OV�RF'.OW SEEPAGE PIT OkFlINF1ElD I he eby aRirm that I om e empt f o ihe CoMractor s Gcense- exrN,cessaoo�oevwe[t MANHOLE . i 4��� Law for the followin9 reason(Secton�O3I.S,BUISfIB55 Qlld Pro- ALTER.�REPAIR'OR ABAIJDON HOU$E - ' � �� �"iOnS CoCJe�: SEWEROR OISPOSAI SVSTEM ' - -� ,�I,qs�owner af the property,or my employees wifh woges as r �� ���' C � �their sole compenwtion,will do ihe work and the strocfure � F j�L`,.,, � �is not intended or offered for sale(Seciion7044;Business - - ' ' " . � and Piofessions Code). ' OWNER'S Permii S �. �j .a y .r.',v,`%c, ❑I,as owner of the property,am exclosively contrac�ing with AUTHORIZATI�N T0T�4L FEE 2 rj� (' � . �iCenSed Conifa[faYS f0 consiruct ihe project($eCiiOn�044, I HAVE AT THIS�ATE A CpNTRACi WITH iHE HEREIN NAIAE�CONiRACTOR TO i�'��i i'""''v2 V .':.'�'F',,`> BU5ine55 ant�Profe55ion5 Co(�e}. CONNECi THE AdOVE DESCRIBED EXISTING�WF.LLIVG TO?HE Cl18uC SENIER. �.. ,:..�:,� CONSiR'OCTIONIE?J6MGICGEKfCG' .��..,..... .._. ..... �^ c I hereby aff rm fF�at-there is ❑construction lend ng ogenty � SIGNED 7HIS D V OF �� 19�v � fo ihe pe formance of the work fo which th s perm t 5 �NER OR � ��j^�� � OWNERSAGENT rj(✓ rssued(Se<.3097,Civ.C.). � 8225 B�EBC.'�LWQQ(I� .n'p'.. ,�.'t8 O�Jl'�. � ' ' � ' . ' . - .. .. , . .400RE55 _e Lender's�Name ... .,.,.:' ... .. �... ... ,.. .� . .. ... . _ .. ..., ,.._. . . � . � .. .. ...-.>�- - .:....:. ,. - .....; _.. . ,. . . . . .. . ....;..: Lender s�Add ess �. . . . . . .�... � _.. ...... .�.:.. . .. � .._ . -.�,� . .. , __ .._.. . , . ._ ,.... .. .._,.._...... . . .. ... . . . . _... .._.. _.. . . � �I certify ihai�l have read th'is applimtion and stote ihat the ' ��� above informqtion Is mrrect.I ogree to comply with all County � ordinances and�Siate laws reguloting Plumbing and Sewers, � � � 'and�hereby authorize representatives of this Counfy ib enter -��" � - � � � ' ' � � � - ��G o'1 above tioned ro er for ins ecti n � P p p ty p purposes. ��G��V7�'�' f G.� �� Siqnature of Permiitee Dat�r SEE REVERfEFbR EXPL`AtJATORY LANGl1AGE��� '-' � � � ' ' � �� ' � '� � �- � �� . ' �a:�.�:::��*x'�. .... . ... .....:,.. ............. , . r„ , , . 9TISPECTQR'S MQTES �. _, �. , E3 �4� .., :.,�:,., . . . ,�� ;�� � � ar �9�vvl�dk��ir.[1��3�;I�' F�3. _ Ti�31�i .rE � . .,�. . � . , - ... " . ."'tl . ' '6 'sieaa*s. . A�P�Q��L 9 �A7F iN5PEC0l25 SIGNATURE ,_������,o�__,_ _ ��7�'U,�8.�iiiv0 R$iBS'.F s5l z*.x�Cii�'�8it5 kii�W13YPSCk+3%'s NEW ii'JUSE 55:tH.R � ' LiC2ns¢S..s°8.+fOi EE:2�O�O'W?n�P885AP�(lCRSDTi yD3�.Sr ..__,�__� � I .. .......Brrsi+isrs,eaad ri'taf2ss:ar�� e;o�eJ:nsy rify or rour.fij, � —.--- .. mNNEcznnomor�ni �� : . .. .... . .. , wbfck re udrss a pemsva trs c�o��rxv�R a6taa, Fsr:�hrove. 9 � ...... BUIIDING OR WONK ' tfe0A6I14Jir tIP YB}h:&�9'GWy SEY7ECiiiYE grrxo,:��gPs'%Ssvaas.sce�. � SEPTIC TAN%.SEEP.A:T(5) [ � . .. . .. ...,...,.,..... ...... ..,,..... _ —..."""" � AND/CM DRAINFIEID . i . . . 4�56 i"BQT69T�.6 $3�TII i8yb')JEGYiSid fOP 396t�k k3�3`mSR',4PD;�f6 4 — � . sigaed seutemaa�:3b�at he ss dir�ntss�yawrac�sai tr aise . ,. cessaoo�❑ o�rnat❑ f . . . . . • ._ - ,,... ." . . . . . pro�n,�soras o}tls.e Caratsscwr"s L'lsettxe 3aw dCSsptar 4 ::"; ALTER,R'cPAIR.SEWER OR —•_,� A, ...' - '" .. ;. .. tLYi4)d90D6f§C9Ng>EUd$T1.SSc'2f093 7'JdD�ll oI�au�saor 3 m#'ahe '" SEWAGEDISPOSALSVSTEM . . . . . BtlSZ7i8d5 ax�.Pra�eassos:s CodeJ nr tl�cx§s fs axempa DISCOiVNECT PIUG AND ' ��.`.�. ABAN�ON HWSE SEWER �� 3TS¢�:qF aii&v^.f36�1G:SS�OC".lie bd�3g8d dlXcfR�4$90�.1�R,'}' . . . _....,. .... -,._._.....:viaTatsoriaf.F�csf,we703�.5�yuny,upp2irantjorm¢¢o»�t ,. BACKiItL SEPTIC TANK$Lj � :-. s�eP,rrt�s)O�ctssvoots u �_ _ . . . . . .. subjecza.t3�e a�ptscu�sa 'ardC�eaaaJry af raa:�ore xba+z ` ,., c.. ��. _ ' � .r s � _.. _..._.. .. h� a�dred oTlur($50t�j.s . ,r,� -. ... ...... - ._.- ...... �.,. - � � ,.- � _ . � . � I,as ihe asn-nee o£x'�e � �rafC cso f:��sdt�ik,ana ��� .: . . ., .:.-,: .� . . .,,; .. . ..� . ,;, . ,�.�r(.�.,. ._..... ... ._ .. _.,�� the stsu�eare ic aot irixended cr��£eeecY fox sst� . .. . .�.: . ".. , T - , _ . . ...... _ . ,. , - dSac, 7'544,8xr,elsaess and Peofa�s600u�a�T•e: �"""o�s- �:, � — . -� ,._.. �, . �.� . �� . . ., �^,` . .��-.�... . . ..;..:, .�...... . . ..'",,.•. 'trae7or's Le,revss�e'.¢w dnes es�nt a,6yty ao etsz a�4 �eyT �, . , .-,...` � . ...-. ....�n�¢r3y:.�bo 7Sus7ds ur 4as�rooer Ebereon.�d mbo does , . ._ .. . _ .. ... .. . _ . , _. � . . " : ' �� . . ._. ..�•..' . ... ... �. .. sueb aonrk hinzael}pronAdael sbat sucde imajrrorrs�eeaSs � . • . . ..... _ .. .. . ____. :�. ' . ' . � .. .. - are''nat intesarlea ar oJfered fcr s¢de.If, daawzvea. ¢be - '. ,' ` , Suyddixig sr d�eaproat�ieni'z;'sa7d wat8ss nrsr,y¢wr of _ _.:, . -- _; _ . .;:,� � . a� ' ^ � �T`"' eaxiplesio�s. �3ir e�u,zee.�-bea3t�ar wi�l dazvr: :ne �scrccen ........ ... ..__ . . . .. . _ . ., . .. .. ... . _..._.. _ . . _. . , . ,. .. .. . ... ... ....::- . . ...,_....�., _ - .; .... . ,..: � . ,-.' �.,- .. ..:,. �,,.. . ,. � .�:o.f?s'oveva�#.`sa8 ba idid ma�"trniYd a.sr..brave far a¢ � � _, ;.. .. ._. .. ..._... - - . ''.r. "�.��- . . .. .. � _ . .. . _.� . . p . � . . �rorarr�osa of xale.j � �., � t r�' . . . � , � ;�;, .. , . , �O:Yd�YOYaYY,�.:a�H�',�• . .. � . .. ; , . . .. . _ . . , . . .. . .. $��,�.�b7T 2�]E3��Stl1Y__._._�._. - . . .. . ... .. . .. . . . .. . . . .. . .. ...,. ., _ _. . ._ . . . . . . � - ., ... . . , . s . . . . . � r� • . �� �., .,,� � : . ��:.s � �,.. � � , . . . . .. .. ... _ . . .,—_.:. . .. .. ,. . .�... . . . . . , ,.,._. _.... _.... Date ; , � :,_ ., , ; ._ . ,,,,. ,_ .,. � ..,... t�x�er ,..... .,-,,. �.,_..,_.., .,._....:...,__.,:��.. ..tim_,���.._.�.... o�„,. ;�,� : � F�iSPECTOR'S'ASOTES ... . .,..,�,. . . ...:.:- -...,. . . �.....c.-... ..,..,..... - ; . :. . . ..;rr _ :.>: .,. . . . ... . � ,... . . ;;... '�... . .,: .,..... ... .._,_ , .. .....,.�....,.,.+�n.>,.,e.e«:.»,�.. .'^'.„..-, .r,ar..v,h?'�*.s�+eas.r.w�n���Nrar-�Mwww.rv:�Kwex.mxv.n..a:=.,-..,.., , , , ..a .w....w . �. .....,-�+....,.+.+,<..<.,,,w . d, . � . � . . , .. ... .... < .. .,;. F . r.�.�. .I ..�.y. � _ _:"�a':..�..._ .:6a i'.,� J:x.-�..-s,.ans}cT"+3ra<.*vYc i .t_'t»i4nYf��eM�e�:t3@u'c.3x.. ..,.... . . ..... . ..�.� .�.... ...«....r..� >.,.«..., .s'.:.l.�p'K ..�..0 a.ar�p.wxw,...r.w t... �.i✓tY4•sr�x�..��fk'WMtj,+ruq"-?>vsrw.[+'�y{r �v . - _ ...,._c...i..w ,.., ,:_. . ., . _ ^ .. Uc ., r � . .. -. . ��; . . . . . , . . ,.. .. . . :. �. �� . . ,_:._ .�.,..µ .s a.x-y'\" :..+w.. �n..:�a...., .. ...:..}:m x.,...H.i ,.A,,.w�.n. 'N�i . .. � �3.4w +�r'r �x�.....,.... ' '} �'n. �.:.:.�.. ._'... :.,',. .�.",.( . . . .:; . . ' . .. . . ., � , . . . ..,M'..�.�� . .... ... .............., .._.,.........-...�a..�wu..a.nmteµw.y.Wz+:'.+Aro '.wwY:+r�e`-a4.�i fw`ynmt�90o'. asWl�+... y,ymyvu^K�� was-w+ib+ae' YM!{?'yoB*T!� . . _ . ;'AM�.;iy'M`"J' . � .. . , . .� � ,�....... . . . ,. . . . . .,. �: '.. .:.., ..'. e � . . . .. , . . � . . .. ..... . ... .�...� .......�.,.............,,...., .x.->� .........;p.,....,....e..,.-,e... yys.w.>e�.?`"`'irMi'�'w°Mm' . .. " A^3�wTF1H'e5�?.✓wn`�y*i'AFkw>rtYr.A✓N.4!m- , .. . . .. . � .,. �.. . . . . , . � ' . . . . . , ......... � .... ....�. ..� .�..�e..-.�..avvn�nrau�.....�u..x...,w.aan�w.mmnmwrerWBl'aP'#Yr+eY#e&ifi .. . ...�twhwN�+x.dlWd,Hp�'tl(NJe•.w�a:�as.v:y ,___ ....... ...........r..�...�e........n......:m�...,.s.:.. .....a�,,,av«...�.u..+v.v<,w-rv_vmn�.wvwy� "^�Svi;w w#tw"r..r ��wF.a"'r�'N�'"' . .. ... . . . . � , r ,.�y�, x�„yxr. ,wcaa�..�. . . � . S�C:'•, . § .