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HomeMy WebLinkAbout1564A , _.a.._ :,..., �_..-:.._ ;� ...: �,��. ,.]a . �_a._ s„ ..:�.M�,,:.,: _: , _ _ _ . _ ._. _:. � . _. _:.... - .� _.�... .__._. _..�...:R �.w�.� . � �.. . ....� , ,.M,,,..,.�,,...� ...� . 1� WORKERS'COMPENSATIOh DECLARATION ' I hereby offirm ihat I have a certficate�of consent.to seif , .�, � , , , , , � � inwre,or a certificate of Workers'Compensatron Insurante,or 7eana4o acerr�fiedco �'Fir� (Sec.39b0;L C.} � CEb08(R'.V.B�BI! � - Policy No., ompany ��• ��d . . �s APPLICpATION-. FOR -PERNfIT ❑Cerlif ed co s ereby furnished. SEWGR - SEWAGE'DISPOSAL _ �'Ce�uFied copy is filed with the counry building inspection COUNTY OF LOS ANGELES BU�LDING AND SAFETY' `�"'"`" �-.°�deportment. - � Ddt S�3 o,pplicant �.'• 1+'T6�'tfI'dT1 FOR APPLICANT TO FILL IN CONNECTION DATA �'CER71KiCATE OF EXEMPTION FR6Ni�VJORKERS' - � suuoin�c STATION cearH . � � �CO/vtPENSATION IPf50RAtJCE '�� � � �_ noozEsS �L. r � � .{TF s sec�on need not be comp�le�ed�f the work involved by�the � �IA� � � �r,NHoiE gEFERENc� uvaER -pe md�s fo one hundred dollars($100)or less.) 'OCAL1iY ��- . �owea NEAREST � �i/' .A �YPEOFCONNECTION ,ENGTHFROM �� �Y certify�ihot��in�ifie performdnce�af t�ie�work�for which ihis � ceossst. 14:��ic1 y, cuRe a.�. .^n,.�7ov.� �permit is ssued,I shall no1 employ any person in any manner o.C.NO. ' ��so as to become subject to the Workers'Compensation Lows. oyvNEa T�-I�,' Aj}j � � co.iMa.No. �oe No. ���7� � � �"' � '�� �� ��� Tyn � TRUNK PERMIT NO. ROAD PERMIT NO, �' Date Applimnt -� nooResS P� :�V�- 2 , NOTICE�TO APPLICANT I{ a{fef makin �this Ceffifi[ate of AfFiDAVR WAIVER EASEMENi RECOR�.INSiR.NO. DAiE 9 CiTV �OV� `d TELNO. e .: �^•mption, you should �become subjed ro the Workers' LEGAI C� � �pensation provisions of fhe Labor code,you must forthwith oesce�anoa �orNo.___ d r:wr.oesr.wioeNin�� wmply with such provisions or fhis permit shaU oe deemed ���I'e'VokefJ. BLOCK TRACT' SiATEENCROACHMEN' LICEN�SED�CONTRACTORS b�CLRRATIOfv � � � � - � n�o.oF etocs. °ER^^iT No. , SIZE OF LOi NOW ON LOT� � I hereby�affirm that�l om licensed under provisions�of Chapler � uSeoF ,,, �.9�(commencing with Section 7000)of Division 3 of ihe B.vsi- auuoiNcs S1T1 �ES a{neces �� "ness 6hd Professions Code,and my license is in full forte and effeCf. CONiRACTOR F � ' CONNECTION CNARGE FEE ' �,. ;; ___......__. a L cense�N�mbe d.`I�d�R`%��L c C�O55 �!�,Q, ADDRE55 ' REiMBURSEMEM FEE � �ISTRICT NO. GROUG MAP PROCESSED BV v �'� - COntrac�or m• Freeman��oa,e �8[20/86 Cirv TE�.rdo. . „ ta _ g� BK � p ❑I am exein t untle Sec of the LA.Co. SiaiE u . L . P ,. :,, _ , LiCEN9E NO.. CLA55 ,...;. .���c, ,,. : ry �. .,_. ,., ... ..:.". : H � � Plumb ng Code andio Sec ' 'of rhe �� "o oesckiPnoN oF woaK �ve� - � FinAi _ , a � ��., , ,�.-� � ;- " ��- �'��,' HOVSE SEWER CONNECT,NG TO � O �aiE N B &P Cade for the following easo �usuc sewea !�`z6^8� VAl DATION . . . . .. .. ,. $EPTiC TANN.SEEPAGE�pIT OR . . . ......... F'�NAL a . `.'� ' .. " . . . .... '.'.. ': PITS AND'O4�RAINFIELD . _ Date . IVOl15E SEWER CONNECTING TO - - BY �� � ' � � GRiyp7E�ISM15Al SVSTEM . � $i]ratu�E .. .� .� .� �'. � •- .... •� COVNECTApCI?IONALBLpG.OR. � '����. �OWNER BUICDER�bECIAi��TICSN "�-��� "�� � - Y+oRKTOHous�sewex ' � ' � � � I hereby aff m iha(I om exempf from t6e Contractor's1'wnse ��� �NF��Eu5P60lGbRVWEIRIAMANNOIE � aw�4or ihe following reason�SECt011 7O3�.S,BL115IfE55 alICI Pf0- AITER,REPAIR OR ABANDON HOII_SE - `,�(`� � ' '' r�ryonS COdeJ: � �� SEWER OR DIS?6SSL SVSiFM� Y � � �"t• . .� I,as owner of ihe p�operty,or my employees with wages as „ � � �� , i� , � � their sole compensarion,w�il do the work and the structure is no�intended or offered for sale,(Seciion 7044,Business Permit S + " "= '�'`�u . .artd Professions�Code). �� � oWNER�S .��.❑�,as owner�of the property,am exclusively contracting with AUTHORiZ/1TION� TOTAL FEE, {"" `��y��_�%i i u � licensed coniraclors to construct fhe project(Section�7044;�� � i HAVE AT TH�S DAiE A CONTRACi W�TH THE'HEREIN NAME�CONiRAC' R TO ��:Buginess.and Professions COtje�. CONNECT THE ABOVE DESCRIBED EXISiING OWftIWG i0 TME v,U9LIC SEWER. ., ���y""'�'j b � � "� CONSYRUCTI6N LENDING-AGFNCY �� n � ,,,ttt o ► � I hereby affrm fhat ihere is a mnstruction lending agency 9GNED7H15 G � OF '�ub .__I9�� fo fhe pe formance of the work for which ihis permit is owNee oc OWNERS AGEN? ; �ssued(Sec.3097,�Civ.C.). , q�oREss 5 Beeehwoad r .��.�$ IIl3 � � Lender's Name , .. . . �. � . .. . .:. . . . . . ..: . . ' .. ' '::' . . . . .,. .. . .. ' - . '��� ' .:::f,, _:'t;?i: i..:..r .., .�. .�.^ , ..-� Lende�'s Address . .' . .._.. ,�:,.,::r . -... , �. � �. , „ . � , . . . , ,, ,�.� ,..� -... ... . ... . . ., -� . '� � I cer}ify�ihat I have read ihis applimtion and��st6te ihaf tlie � � ��� � .�� - �. - � � - � � � � - � - � above informotion is correct.I ogree to comply wifh qll Counfy � ordinopces and$idte lows regulafing Plumbinq and�Sewers, � � � �' � �� � � � ' � . . . . . . . . .. ...... .. . � and heFeby authorize representatives of this Counry to enfer � �" � � � " � � -�� �" �� � - " " � � � �n he abo enfioned property for inspectio p�rp ses. G��«��o �� ���� ��� - �Signp�ure of Permiftee Daf� SEE REVERSE FOR E%PLANATORV LANGUAGE . . . . . ., - . . � ,.. . . . . . , � , . . . ' , ' .: . ., ,. . . . . �. � '. , '. _. .: . ',' . ..' . , .', . . , , . . : , , .,:_I: �, . ._�. ,...;.... t'' ` ' �` x,.'�_.:` � a ,� - Y_a ,r sz 11�9STESTO�'S�F6S ���'l��t�"3��.�����'�i,.'f!e`��"i'�QI� _ . ...'f.K: '.5¢'93:p..� ..... n :. > . . . .s. c � , ��P��,/'�/.A�,� DATE INSPECTOR551GNATURE � __�.,.W.�...,�R�_, . Y'Sia'eS�g'3a{iYFntFE:iCI�SC:eX.2i.,6]3'i�fRC�In'[P'i@'G01t28CCOt'A � � N�ty�toug�tv�A „ Lzcetlse;.swv€on tlne tolio;viag rea�oie jSeca#oaz 70�F.5, , _�� " Srssixess e,od 3grrafeasaeo-ms iwsde�:a4sy cie,y or;nuttty CONNECT ADDITIONAt wbsch x�qwirss r�.¢ermdt 3o soa�sdruct uY'tar,4n,pzreve, BVILDING OR WORK . ' $EPfIC TANK,SEEP.PITlS) Ir61PSO1L4�sr 4iT.YE�/2RY.:'Nf 3(t9"ebr,nPiYw'e j�'�d��d���;4SSYtQ2°.CB; AND/OROR4INFIELO xt�3�9 TEqP.:3Y&.i SJY�Y pi�'1p�Yfqy'G`%$F,j'QDJ"SYCC�J'�lBP7iiE i0�SYE G �ssvoo�Q DRYWELL[]..—�L---^ . . . . ... . , 53843C6 5'ba�"'ll'YlJ2i4b ki�t Se�.fa i�eeused psasseuaxit to abc �t . �nvim�Cons of!he L'otttrurt�r�°r Gscetat�e�w dCbaptsr 3 ta - AlTER.NEPAIR,SEWEft OR � �4159L39FQf1LY%g 3pRSIl.SCLSY04Y 706D>y/➢iv&sian 3 of«bs SEWAGE OISPOSP.L StlSi&Ll --' � � . Beasawess�aeaaC Pscfe�saom�.s��'oste�er tSat 8e.'s asara$t �s• .. DISCONNEC'PLUG.4ND ' . . dJ�EP2 OfrP3 uZY.A S�J&SQSJ9 6r�p 6I�2 C(d RS'E1lE b'tOHI.Ari' ABANOON HDUSE SEWER � � S P� ,f� BACKFILL SEPTIC TANKS❑ � �fO�RL01T�.S3Cs^LA£2 7T1���'J',y�'e'rii,'j/tldpfiFYC&TJE�Of 6'�1tlYfa2f$ ScEP:GR�S)❑ CkSSPOOLS❑ � 3lS�FCLS 3gJP Afi��4C�A$AG fi.'.,'S�Yfi�f3E5E1F�$JI Of 5fl6?AOPC$bkYh : ...;. .., . ... . . . , . . (.t (�`u�0u��2 � ���' , ^..... .,� .•. "� tJ8LS9 NC PE ,. . . -...k „7iP3C �J ,;. . . _ . __ . _ .. . .- :.. „ . . .,: - I,as s�e rrwster of Y�z±n�a�ap�ifiy wil@ do th�z svosk,and µr.:-.._� i � - . �seraeture is aet n�.c�ded cr affe:ed 4zar ae:e. , .. ✓ ' ' . .. ..... ... . .. ..... .. .. . . .. . ._ . .... ...�;�. �. ....dSea 70�r4..�3uu�iasu�Pro}essimas�L'ode:T,''�'s�w , �� . - . . .,, __ _._. .. ._.. . . - :, a ��_�. ... ...�:.- '�i,, .. � � 'r's L,c_.,e iLatu does rzot !y 8o tux os •nf . : _ _ .. . , r,,�z�., , �. �. .�P$ �:��- . , . 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'7J . . . .. . � ..;•. . ,.-����E.,�.�.f�f L�135 i��{3Yi�. . . ..... . .1 . � . - """" � � „ . ...... .. _._ . ..� . . . ._, ' y .. „ . . . . _. . . _ .. �� � . . �$� . . . � , _.' _'.. .., ._... .. . � . . .. �}A/Yltd' _ ' _.—_. , . , . . .. . , .. ._.. , _ .. .. .. .., � .. ._- _, ._ . ..... .._. ...... , . . INSPECT�R'8 NO3� ::s� , ,. .,..,... . . .. -.�, �. . . . . . . ' . . .. . . . . - � � , �: . , .. .. . .. . " ..... _ . ... r :. . ��_ �,. �} � . �� �..�� �:i:�. . . . . � ;. . .�- ..__ ...._ ... .-. ..,a, _ ...-_i� _ _ . .. . . _. , .,, �. .. � ..;,, , , , . . . .i., . .. .... , . � �� .G� . ',�� .. . ����' � , . —. . . . . . . , . ..... . ... . .. � . :. . � yr �-�� ... ..- . , , .. . _. � ... . .... . .. . .. ., .._ .. . , ,. ..-. . ., ..- ,: �. � . � (� i't 1Fj,v . '..- . . r ` .z . � . � . :. -.z..�:s.�, . - . . - :, � � , � � ,._ . .:�:.� . ... - . . , .. , �, _�"' j ' . . .�.,}:.: .. _ ° .... . � ..