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WORKERS'COMPENSATION DECLARATION � ' � �
I hereby offirm thai I have o ce+eificate of consent to self ' i7
iasure,ar a certificate of Workers'Compensation Insurunce,or '6�6'�0 _ U
� a ceNified copy rhereof(Sec.3800,Lob C.) �EeoB�RE°.�,83� qppL{CATION FOR PERMIT
PolicyMoi�0011FiCompany Pacific States Casualty
� ❑Certified copy is hereby fornished. SEWER - �EWAGE DISP�SAI
� �Ce�tified copy�s filed wirh+he coun dtng i ection � s OUNTY OF lOS ANGELBS BURdING ANQ SAFETY
deport-e,}�
Dare �L� ��Applicanr FOR APPLICANT TO Flll IN CONNECTIpN DATA
CE TIFICATE OF E PT N FROM ORKE ' euno�r+c 3,�,.��
� COMPENSATION INSURANCE ADDRESS ' 51���ON o�v�H
(This section need not be completed if the work involved by 7he ��q��n, Wa 1 nut, Ca 1 i fo rn i a 91789 M4NHOLE REfERENCE ��Q�G q ER
permit is for one Mundred dollors(S100�or I'ess.�
I CB�Iify fhpl III �hC performance of ihe WOIk fOI which this NEAREST TYPE pF CONNECTIpN �!-� IFNGTH FRpM ��
CRO55 St. V, CURB K,y/ M.l.TO P.L.
permit is issued,I shall not employ any person in any monner
so as to 6ecome subjed to the Workers'Compensotion Lows. pwrvEa 1 s t Na t i onw i de Mo rt a e Company CO.IMP.NO. B NO. /�O�I
"•^'� 9 00 S. 52pulveda BI V(j. TRUNKPEAM17N0. ROADPERMITNO,
Dme Applicant noottFss
NOTICE TO APPLiCANT: li, after making 7hi5 �MtIfiCOfE O} CIiY L.A. CA g0045 TELNO. \2�3 64z-o2 � AfFI�AY1i wAIVER EASEMENT RECORP.INSiR.NO. �ATE
Exemp�ion, you should bemme subjec� to the Workers' �GA�
fi"�oensation provisions of rhe labor code,you must forihwifh o�scaiarioN lOTNO. HWV,025T.WIOENING
� ly wi�h s�ch prov'�sions or this permit shall be deemed 39833
r�.�ked. ' aioac iRAC7 STATFENCRQOCHNFNT
UCENSED CONtRACTORS DECLARATION "p,o�e�°�5. ' a�aMiT r�o.
I hara6 affirm�hm I am licensad under SIZEOFIOT raowoN�oT �,7�
y provisions pf Chopter �SE� '�A/'TpTjp
9(commencing with Saction 7000)of Division 3 of the 6u5i- BVilDwGS anrzces
ness ond Professions Code,and my license is in full force and
eff¢[f. CONiRAC?OR CONNEC710N CHARGEfEE
license Number �iC.C�OSb AODRE55 W i 1 s h i re B 1 vd. S p REIMBURSEMENi FEE �
CO�flOC10� Date ��tY [ - DISiRICi NO. GROUP MAP SSED BY d
L.A. CA O V TEl.NO BK PG V
SiA�E 446 10 °�.
❑1 am exempt under Sec. of the L.A.Co. ucENSe No. 7 an5s B � ;3 � Ioa�1 e,n p�
NO. DESCRIPTION OF WORK FEE 0
Plumbing Code and/or Sec. of fhe ryp�5�S�ER CONNECiING TO ��.. OA E� VA41DA'FiQM?q �
B.8 P.Code for the following reason w �
SE IC TANK SEEPAGE PIT OR p.
VITS AND/OR�RAINfIEIp F�Np� ��s t 1 (� y
Date �{p�SE SEWER CONNECTING TO BY � ' ' �
PRIVATF DIS I.SYS1E C r �
SIQlIOtU�B CONNECT A�DITIONAL BLDG.OR I "� °C��`J �
OWNER-BUIIDER DECLARATION woRK To House scweR
I hereby affirm thor I am exempt from the Contractor's license �rniF��ssrooiGORrwi�iA{inN�iaw ` ° •��S G y
Law for4he following raoson�SCC�00�O3I.S,BU�S�ESS O�fJ P!O- AIiER.FEPPIR OR ABANDON HOUSE '
fBSsiOnS CodfJ: SEWER OR DISPOSAL SVSiEM (�';',7 � —,Fy S
�:os ownar of the propeny,or my employees with wages as Re s t room Fa c i 1 i t f0 P �Q�x
rheir sole tompensatio�,will do fhe work and ihe sir�clure P � Area .
is not inrended or offered for sofe(Section 7044,Business
and Professions Code). OWNER'S Permii E �
❑I,as owner of the properry,am exclusively convacring wirh AUTHORIZATION TOTAL FEE
licensed conlroc�ors ro construci the project(Section 7044, i HAVE A7 iH15 OAiE A CANTRACT WIiH IHE HEIiEIN NAMfO GONT2ACTOR TO
� BUSIf1855 plt(I PIOf05SiOf1S COfJB�. CONNfCt TFIE ABOVE OESCRIBED E%ISTING DWELIING TO THE PUBIIC SEWEF.
CONSTRUCTION LENDING AGENCY �
I hereby offirm thal�here is a consiruc�ion lending agency SIGNEDTHIS DAYOF 19_�
for Ihe performante of ihe work for which ihis permi� is OwHea ox
iSSU�tI(SBC.309�,Ci V.C.J. �'NER$AGENt
Lendar'sNome lst Nationwide Mortaag„e Comoany "ooaeu
Lender'sAddress 9800 5. Sepulveda Blvd., LA, CA 90045
�certify�hat I hove read �his application and stata�hat the
abova Informalion is correcf.I pgrae to comply with oll Coumy
ordinances and S�are la regul ing Plombing and Sewars, . �
and hereby au�h ' epresa tives of rhis Counry ro enier
upon�he a - entioned perty for inspecrio purpo s.
�$ �
g�ofure of Permi�tee Do e SEE REVERSE FOR E%MANATOM LANWACE
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i� ro�'s rot�rc«� Qt�'NER-�tJ�i.YS�ff 1JLi.'Lt�,t1'Iffl�
_��'a�r+�__ ��<�
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a.�._ S ,��. 1 '�,5,$ __�� u 5hF- .'Ss�s.la+ � __ _ '___,_______'_„ ____ I lxreby affirm that 1 am exemg!Ikom ihc Co4Plraetur's
�, �.. �_�I �-. � �h � lic�nsc GaH�For lhe fitiew��iQ reema{5eerime 7!)1f.5,
�� =�---{- '-- .—p ___ __..-_... .___�. :__. ___ , B+c�,n�s.e oud Prn/essions Codi+)r hm'ciry or cuus#v wRiek �
� �� �.� �r �y. I . __i � .. d � � � � req+xrei�a perneH te ronstrud akc r,iinprrne,d�k,or
.. , rr _._�__-�,- --_ '_...'_ .t _ ____ .____. -._, _--- _—_. � repwr mw s,rurture,yrierlo 11v tss�eanre,nf+A erqiebe�thr
r s�. 9'
:.�a o N:.i .. � � .- � � . - � . . � -a➢R!iruwt fnr.euel!�nrti(tn lFle n sig+�ed sN�emrnt fb�tl l�e�ia
'" . . _ _�__.. ..�_'_ _.___'._ __'_-_-' .
�' O .�O � I � ---�.. . . ------`----------- —'-. licensed psrceeattt !o tAe prm^neemes nj'thr�L'rmtraclnr's
�. � _ ' ' -_y� _ _-� � .. � . /.icense l.au(Ch tr 4(commemcing»rfh Ser(ioa 70FI(11�f
�`*'R a� - � � '. 1 � � ___�_ . .-._ _.._ ._.- .__..._._._._..__._____ bi�icmre 3�f t6e f3a.st�esa¢akl7ofessioa�Codtr)or lhetlre is
��, r .. . . . . . exen�pr thrrefron�and!hc hssi�f rr!hc r.eNtic�yc I exc�'n.re.
„ y H x.- F,ti � � '� _ � - � Any��oIahore of Sectrun 7B3I.5 hy arry a�Lcanf,fbr u permit.
i � .. . � � - � : . . � .� � . .. suhj<cLs fhe applicmrt tn a ci��il ycnalry�o(uot niorc Naus,�ve
.. 7 , r� � � � __'_,__ . - {nneArrd doRr.rs l.�SOBI:
:, . _,.._....�.._..�-,. ,___�..._...�__.._......_.._..�.,., r-----------------.��.--'�.-� �L�1,us the owncr of Ihe pruperty will dc�tln work,and
. . � � . . ' . ... ..�_.__'.___,__ thc struelxre is�rot in[en�hvi or oRhr�t ftre spte.
. . —_.__.__�_.�.....___ .
. � �. . . . ..� .(3er.7Aak,B�esi�ess uxQ Pfofessiorr.e Cnde:Thr Coretrn��b�i e�
`____„___ _ Lrcrnsr Lax•does�eot�v tn ax ow�rcr of yropw�rv w�a
� -- Gwlds m•ien�ro�-o�tAurer,n,a�ed wkn rk,es s�rch wurA huu
v
. . . _ "+_`J____.__`________.___,___" ` Proritkd[ha,'such ie�e�roveu3enfs are nnt ire�cmkd ar�y(,}.
. . . � � � . . . . .for sm�r.Tf,7eewev;r,f/�e bue7dbrA or i.ppswveam�rtl i.a sold
. . . , .. . � __ _-.-_.__ __..__. _____._:_.___'_._—_.___ , x�itkix une yearaf cnr�pirEme.lhe nwrrer-Laiklar n�ifi hr<v�t4e
. . . .. . . .. . . bxrAen of praMna[he[ha did iw!M,ifA or i��rnvr fix Ihr
. . .�-�_.._�._------__----�-----------.- ._ �. P+frlw.reof'snle.l . � .
-------- ---------`- - I am exempt�n�rar Sec.---- ---•
--- -- - ___ _ ___.,_—_ .------ t��r.c.eo�rn��:�n
. -- ---- - U��e — �
. ----—--- —---------- owner
--r:��:�'�at.':c rao�r._ -------