Loading...
HomeMy WebLinkAbout0896A WORKERS'COMPENSATION DECLARATION � I hereby affirm �hat I have o cartifitate of consent ta self S'� insure,or o certifico�e of Workers'Compensation Insura�ce,or 16Ad°Zo U o canified m y rhereof(Sec.3800, b C.) CE BOe:RfV i/83; Poficy ���� �om��� APPLICATION FOR PERMIT ❑ '�� SEWER - SEWAGE DISP05AL Cenified copy is hereby furnished. � .�Cenified copy ia filed with the coonty boilding inspection COIlNTY OF LOS ANGELES SUILDING AND SAFETY , department. ' Date�„�Appl�cant FON APPLICANT TO FILL 1N f S CONNEGTION DATA I CERtIFICATE OF EXEMVTION FROM WORKERS' g�iiw� p I CAMPENSATION INSURANCE ��ss O W��IOMr tc6� J7Y ST°'tww /D f� °Evr� i � (Tbis secfion need not be completed if Ihe work involved by the nwrx�E�FF�tEr�E uwER I permit ia fw one h�ndred do4lars(j106)or lass.) � �«P'��� � � 1 cenify that in�he performonce of�he work fw which this �utpss 5T. - Trff oF[anr�crion ��T„p� � permit is issued,I shall not employ ony person in any monner r� cuae v i. �tL.io Pt. � w as lo become subject fo the Workera'Compenwtion Lows. owNEk t C d' pp iµp dp, ��� �7a7 . Dote Applicanf ADD�AESS �0/J 7 Z. 7RVNK RrtMIT N� NOA�PERMfT NO NOTICE TO APPLICANi: If, ofter makin this Certificate of ��oawr WANER EASEMF,Ni acmao.insm.rao P,..h � e ��,Y .�:.� G. ,��.� � -GGd-d o Exemplion, yeu ahould betome subjecl to the Workari • Compensn�ion provisions of tha labor code,yoo m�st forthwiih oaccl�'vtloni IAT NO. HWT.OR ST.Wlp[NIIJG � • eomply wi�A sueh provisions or ehis permit aboN be deamed / ( c (EVOItGCI. BIOCK TRACI {p�/.,7 STATF FfJCGQACMNFNT LICENSED CONTRACTORS DECIARATION r.p,pc�ocs. veam r rvo $$$ SIZF OF LOT Npw ON LOT .�, /. ,n pI � I here6y offirm that 1 om Vitensed under provisions of Ehapter �� aC0 9(commencing wilh Secliort 7000�of Division 3 oE the Busi- gui�on�s anitc.�s ness and Wofessions Code,and my license is in full 4orce and - effect. /��}p 1 / ��Tp,qROp �k,�y CONNECTION CHARGE fEE license Numbero�r J� Y �ic.Class � I �ys REIMBURSEMENI FEE g • Contracfor � �r' Dofe ' wSTRKT NO GAWv MAV �Q gY O6 � Cltt TEI.NO ❑I am ezempr under Sec. of rhe LA.Co. srnte uc. p� 3 Y � ����. «� � �'3 Et 33 � '- P1O. DESCRIptION OF YJQRK ffE � • Plumbing Code and/or Sec. of the crNai O 1 MOUSE SEWFR Q7NNECTING TO oo.r� r— YALiDATIpN �' r vuatK stw�re 7 �(—Z O-b� � s� B.8 P.Cods for�ha follrnvfng reason � 5[PfIC Tq�.gFPAGF PR OR PITS NJD%OR�RAINfIELO FlNA� y : DOtG 4q�5E SEWEQ GONNKSING TO eY Z � PRIVATE�15Pp$Al YS1E j Signature cpwJECSOpp�i�OP1Mg�pG py � OWNER-BUILDER DEQARATtON '�'O�K TO NOlISE SFNER . WERFtOW$EEFAGE%T,D4AINfIflO F � I hereby affirm ehot i om axempi from the Caneractor's license F%iN..CESSPOOt,ORYWELL,MANMOLE � low for the following reason(Setton 7031.5,Buisness and Pro- urta,rstveia op ne�wpow`qu5¢ t ; fess�ons Code?: s�wEa oc o�svosu svs�n � ,- ar.r.0 � ' ❑1,as owner of the property.or my employeas wifh wages as - „ - { . their sole compensotion,will do the work ond the sMvtturo � . is no�intended w offered for sole(Seciion 704-0,Businesa 1:� • • • � '. _ ond 7rofeu+ons Code). OWNER'S Permit S (p ,(�O � I � �275;, ❑f,as owner of�he properry,am eadosively contructing with AUTF40RIZATION TQTAL fEE . ,S'D � , licemed commcrors to tonstruc��he projed(Sec�ion JO44, �qp,y[qT TMq pptE A CaNTRACf WITH iHF HEqEIN NAMED COIViRACTOIi TO Business and Profasaions Coda�. coNr�ct ir+e aewe oexaieeo eaisnne owewrvc ro T�ouatK sewea. • � ".':. ��.�. �.i�- �€ CONSTRUCTION LENDING AGENCY � � � ��_��� � 1 hereby affirm ihat there is a construction lending agency SIGNEDTHIS DAYOf Iq_ - tor ehe performanca of Ihe work for which fhis permit is ��R� owr�uas n�tNr issuod(Sec.3097,Civ.C.). ,J�� � Lander's Name N �E� � Lender's Address 1 I cartify that I have read this opplication and stote�hnt the j a6ove informmion is cwreU.I agree�o comply with all Co�nry ordinances and State lows regutating Plumbing and Sewers, � o�d hereby authori:e representolives of this Counfy lo enter upon the obove-menfianed property fw inspec�ion purposea. ' � � � Si ra of Psrmitlee le SiF REVFRSF fOM iI(/LANATOAY LANOUAGF „4 ; ; � ' S'.� - �'.+ �i, , `, . . I ' y L "�.3'i,` '- G •C_Y�_µ -_ - �1 `.,, `` `` 'fS�:I' ' .• �...:.� • . • .Fr �C� ,^�'= ����l `~C�^V ` -, ~ _� �, - 'r,.s, r✓�� J `�` -�'.��wd �.. Sy^� ' `_.' S_`- '- JrLL .� Y ' , F� • �y _ �! .+� .t_ _ � `. — _ v 4.. J — �� _ _ % _ ��^,— ;n=- ... '�e..'_ ” � �:N . +� '�S „ ' " ^ �. ,L'�i ^ y^ 4 �~. �y.. . . ' �"�; 'J �. _ _ _ _ _ ,i ,.�L.L' � / U M1-_ �� r., ;. . , 1 � . .` . � 'c_. _ `i.� _ -,' " �• ,M��~ �� . ~ y , 1 ` , ` ,, 1• , �� K� � _ �:.� :. - _ '_ ' �\ �.�' .,. '' �- - .�s r_.. . ,- .. `. _ — - , — ••v'' ' '- ... , . ' � 1 �i �1, �, �, ` w- - N . �'� � '� �, '1 ` . � �.� � _ +'•`= _ '- ., l '` �; l �, �t i1 `f . 1\ ' 1 ,1 i '•� � , 1 ` �� 'l ` ' 1 ,� ,'+ % ,l� ` ` � � , , , ,1 y , ,, ,' 11 ` . 1 �,i . 1` � 11 �, .. i ` 1 � , ', �; 1 � , " � . . � `• , , 1 , , , , . i 'l ` '\ ` , lt �` .�,` , �' . . •.' 11 ,,1 \` \ • L �,.� 1 ,, ;11 � t ��. , � � . . , . ', - , . �� ',�+ . � . � , . .� ', i ;, ' ��� • 1�,1 . `' �, '`�� ��. ti � . v�,y �,1 5 . �,L `, ' , ` ' � ' . i 4t�� � ' � ' � 1� ` , � . iR�}'� � . ' ,�` ' ' � . , �'.V�- , , . . , � , f �.��', �11`,. 4 , , , . � - 11 i `, �` . i+ Y�1 , � � � ,,. . � ' 1 � `1 111. 1 t . ; '� .,� , . 1 . 1 1 ,. �; '` '.11 � ,`,, � �� `1 ` ti` ` �1 t, ` '` =.1 I� , ,� ' � �; . ���„�,....�- � \ �,. ; � � , � , � , � � �. �i ....- '� , �,�,.,µ„ , . , . M, 1. , � „' � '� �, o '� � ', „ , � �, ��, "���`; `�' \ ';,.. , ,� ����; ,t� , ' ��• 1 r:, .�`°. ` . i:+,`', ' ,� , .� ', ,:: � ` '�` , - ---,. �:,`�� �i ;, - '� . •` •,, . ,- :` �... . . ., , �•,, '4 , ` , �1 L-�I ' , 11't� , �, . `' �,� '�� . .. �,`}�,4 . ` '� ri� '.f';'�1.^ ' � �� � .(� � '., '..`�,` � � 1: .. e,< \:_''_' . . . �y� c..;, r, �, ,. t. lt r�•g,µ.. :��' 'L � '�,1��., ,, M4 . � .�'t . , t�`) ,' � . . �`` � ~ ''�,..� ✓ y'�� ''