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HomeMy WebLinkAbout1772A � OW DECIAR�kTiON I hereby off�rm rhof I hava a cmtificate of consenr to salf ;1 insure,w a cerfificote of Wwkers'Compensn�ion Insurance,or �aaaaao II �`��� ' ���o�,`�"�-„� `k�s'"`",,°' APPlI�C* ATIQN FOR PERM�T � ❑ca�rf�ad�aP,.is hereby furnishad. SEWDR - SEWAGE DISPf3SAL ❑Ce�tified copy is filed wi�h the wunty building inspection COUNTY OF LOS AN6ElES BUILDING AND SAFETY depar ent. ��� ��r� Da1e_��Applicanf +� ___� FQR APPUCANT TO FIlL IN CONNECTION DATA CERT ICAiE OF EXEMPTION fROM WORKERS' �.eunoiNG COMPfNSATION IIVSi1RANCE �noorzcss 41 •�a STnnor� oecrH (This sec�ion need no�be completed if�he work involved by�he ��A��ir rowwio�t 2eveacNc¢ U°� parmit is for one hundrer.i dollars($100)or less.) � I certify thal in ihe performonce of the work for which Ihis �Rpussr rvacoccor+Necnorv �N�rNfrsoM permi+is issued,I shall not emplay ony person in ony manner Y� CUae P.�. �n1.to v.i. so os fo bewme su6ject ro the Workars'Compe�safion Lows. vC.No. OWNER CO,iMP.ND. JOB NO. ��� iRVNKPFRM17N0. RORDPERMiiNO. Dafe Appliconr nooaess NOTICE TO APPLICANT: If, afrer making Ihis Cartificote Of CIiY iEl.NO. AFFiD�Vit WqIVER EASEMENi RKORD.INSiR.NO. OAiE � mpfion, you should become sobject to the Workars' teGai npensarion prov�sions of the lobor code,you must forthwith oescaivnor� iorrvo. �' Hwv,oesr.wmeNiNe comply wilh such provlsions or lhis permi�shpil be deemed sr>` revoked. eiocK �RAC� y✓ SiAiEENCROACMMENi NO.OF BLOGS �PERMIT NO. L�CENSED CONTRACTORS OFCIARAiION SaEOF�oT No��or+ior I harehy offirm�hat I om licensed under provisians of Chaplar .�pF 9(commencing with Section 7000)af Division 3 of�be Busi- gunoirics — cNnaGEs ness and Professions Code,and my license is in f�ll force and effeLt. GONTRACiOF CONNECiION CHARGEfEf Licanse Number :'��.l�C�lic.Closs � noo2ess �ReiMeuaserurv*r�e y, ) q p DiSTRICi NO. GROUP MAF PROCESSED BY �+ Comroctor � ate �. i arr iEi.No. � "!47^/ � BK � (� y ❑I am ezem 1 under Sec. of tha LA.Co. Srare uc L \ p ���E��� � U �,AsS j6 (R ���.., � HO. �ESCRIPTION OF WORK fEE ��� PlombingCodeand/or5ec. ofthe PU�C�� ���A� VALIDA7iON V rous[sewea mNniecnn�ro onrE B.&P.Code for fhe fallowing reason � �Tq�nt,SFEPA Pir ox �FiNAt ��/ �� a, Pli$AND�OR DRAINfIEID � Doie HOUSES[WEk�OryNECiING10 BY 2 .�' NaiyATE D� SVSIEM. Signature eoraeeT aooinon;ni eeoc.oa � OWNER-BUILDER OKLARATION wo�ro Mousc scwee WER£iOW SEEPAGE Pli.ORAiNFiELD I hereby offirm�hat I om ezempt from fhe Confractor's License �xtN.,ce5scooi,oavw¢u.N,anNoie low for Ihe following reoson(SBC�OII 7O3I.S�BUI3�1955 Ofld Pfp- ARER,REPAIR OR NBARD(Jlti HfJIISF �O/15 CO(It�� SEW4R OR DiS�'CSAL SVSTEM u 6 as owner af the proparfy,or my employees with woges os their sole compensation,will do the wark ond the strudure ia not imanded or offered for sole(Section 7044,Bosiness permit S ond Professions Code). OWNER'S ❑I,as ownar of rhe properry,om exclusively comracring with AUTHORIZATIQN T07A1 FEE t n licensed contraciors ro construct the project(Seciion��44, i HAVE Af iH15 DAiE A CONiRdCi WiiH THE HER[IN NAMfD COI:TRA�OR i0 }�� I !7,(_l�l BUSi�@SS Ond P�OfE55iOI15 COd9�. CONNECi iNE ABOVE DESCRIBEp EXISTiNG�WEIIiNG TO iNE GVBIIC$FWfR CONSTRUC710N LENDING AGENCY �' ° ° ` � � r� I he�eby affirm tha� Ihere is a construction lending agency SIGNEDTHIS DAYOF 19_ � for rhe perfo�mance of the work for which this permi� is owNeRoa i •�-� a'-2 l. Q issued(Sec.3097,^Ci_v��.C.J. owN[as nceni c t Lendar's Nama t.Pri�tl.`'YIE'Fi�f4��. noortFss � " �1�,..;v�� C�'e'3d�ar�ndd�s 1'� �.. —��.�Y"LI��3 0 2 2 8—�q I cxlify�hnt I hava rea �his oppli tiod and stale�ho}the al+ove in{orma�ion is corract.I ogree lo comply wilh all County ordinancn and SMte �aws reguloting Plumbin9 and Sswers, ond hereby a�tMorize rapr,aento�ives of this County 10 enim � upoq above-rnenliorro �ppeny ipr inspettion purpozes. t > 90 r �) ,_-� i rwfvreof-!rmif a Do�e SEERFVERSEPO�l7(�MNATORVLANGUA6i � ... w �. 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