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I WORKERS'COMpENSATION DECLARATION �
I hereby affirm that I hove a certificate of consem to self � , � , � �
insuro,or a cenificme o(Workers'C mpensolion Insurance,or 's"b'��
' a ceriified copy t }a ,��.3� b�. , �E���°.B,B�� . APPUCATION FOR PERMIT �
Policy.No.l.��l/�ompany �� -����" (Di �
❑Cxtified copy is hereby fornished. � SEWER - SEWAGE DISPOSAL
❑Cer�ified topy is filed with Ih!tounty building inspection COUNTY OF.LOS ANGELES BUILDING AND SAFETY
depar�me��.
Do+e .4ppl�canr FOR APPLICANT TO FILI IN CONNEGTION DATA
CER�IFICATE OP EXEMPTION FROM WORKERS' ��ip�
� COMPENSATION INSURANCE �oo4F55 � SfAT10N �. Y' �7 DEvtH
(This xclion nead noi be wmpletad if Ihe work Involved by Iha i���T� MUJIKKF REFE4€NCE � . UP7FY
permil ia for one huodred dollma(5100}ar less.) R
I certify�hat in �he performance of fhe wofk fo.which rhis �aos�sssr. T������� ��T�+Fao�
Y. CUQ6 P. M.L TO P.l. / 1'
permil is i:sued,I sholl not employ aoy person in any monoe�� q.
so as to become sobjecl lo fhe Wwkera'Compensatioa Laws. P����� <' Q
owr�a G co.ir.w.no. ioe No. f/�� V
���R� TRUNK PERMIT NO. qpAD PERMIT NO. :
Dole Applicanf
NOTICE TO AVPUCANT: If, a41er makin this Cerfificata of �FFIDAVIT WAIV411 E�SErnEtit R[CoaD.rtum.r+o. MrE �
9 CITY TEI.NO.
Exemption, yov ahould becoma subjan��o the Workers' IEGA� 1y
Compenwtion provisions of the labor code,you muar forthwith oescmrnqn lOT NO. � HWY,pR ST.Wlp[NING u-
� comply with aoch provisions or ihis permil shall be deemed p - rn
fevOltBd. BtOCK TAACT �p STAiEENCrtOACHMFNT . �
� NO.Of&WS. PERMIT NO. ' �
LICENSEDCONTRACTORS�KIARATION saEOFior � roowowipT .
� I hereby offirm that i om licensed under provisions of Chapfer �
9(commencing with Sec�ion 7000)of Division 3 of ihe Busi- a iu iox,�s
a+�s
� ness ond Professions Coda,and my license ia in full force ond
' BffOCf. ��/'��/ ' CONTRIICI CONNECTION CHA4GE FEE
License Numberr�.:.-�-�-Lit.Class � nooRcss � ' aemneuwsei.�tNT�¢
Co��racto?���S 7�.Date ���-�.E3"�f3 � � D15tR1�T Np. GYOUP !MO vaocasseo er
"— CI1Y TFL.NO. ,/
❑I om exampt under Sec. of fhe L.A.Co, iiCeNSe No. � ctnss �Q �� � �C��`/' ��'��
PlumbingCodeand/o�Sec. � of�ha �' DFSCkiPTIONOFWORK r�¢ Fi��
�a�,sc s�wER cor,+r�a�r+�ro f� OOTE '/ VAUDATION
B.&P.Code for the foilowing reason °�B11C��R � 7
S�RI ANK.SEEPAGE pT OR FlFMt
PIiS AND/Oq 6pAMIF1EID
DOfe �5p 5flyE4 CDAINKTING TO BY
1 PRiYAi Y
Signature cadr+rcr kpo�r+owx&oc.at ,
OWNER•BUILDER DECtARAT10N woreK 7o HWa�stwia -
I hereby affirm Ihot I om exempl from the ConNOUoi'S license E�%T�Nf�CESSPOOI pRVYVE0.AIM/,NNq.E
law for the followin9 reaaon(Seeton 7i131.5,Bulaneu and Pra- xi[k,REr�ia qt.w.Nppa�qUSe .
lessiona Code): 3F�+'ER op D�Svos�L 5�5tEu� 3 0 5 2 2 A
❑I,as ownar of tha property,or my employees wilh woges as �� ���'� .� O
• their sole compenw�ion,will do the work and the shucture . � .
ia not intended or offered for wle(Section 7041,Business
o�d Profeuions Code). • OWNER'S Pe�mit f � • •2 7.5 Q
❑I,as owne�of ihe p�oper�y,am ezclusively tontracting with AUTHORIZATION T�TAL FEE A�f r- . .� • s 2 7.5��
licensed conlratlors b conahutt the project�$�[ti0��044, . I HAYE AT THIS DATE A CONiRACI WIfM iH[HERE�N NAAAEp CONTRACi04 TO � -
. susiness and Wofessio�s Code). cordract tHc neov[oescRieeo eH�snrue owewrnc ro rHc r�euc sEwen. � � � �2� [G s g 3
CONSTRUCTION LENDING AGENCY � / r ►
) I hereby alfirm t{wt there ia a conslru[tion lending agency SIGNEDIHIS +� DAY /'/� �9� � -�
� for the performonce of t6e work fw which,this permit is p�ryfQ�p�NT �A�1� �
iasued(Sec 3097,Civ.C.). � �
Le�der's Name AD�� � '
le�der's Address '
I certify that I have reod this app�ica+ioo and stare that�he -
above informa�ion is cor.ect I ogree fo comply wi�h oll Counly '
. ordinances and Slale Inws regu�aling Plumbing ond Sewers, . . �
and hereby aulhoriza ro rosentatives of this Cou lo en�er
� upo I e above-menN d�� rly for inspecfio purpoees. �
// —/3—�3
$ignofure e millee Dple ' SEE REVERSE FOR E%PIAHATORY LAN6W�GE ,
uasrEcros�s raores O�S'NEP.-EUILBLR D�CLAFtATION
kP�ROV/4L5 onTe iNs.ECToa'S sieninTuae - I hcrcby af(irm t;ret I am ezcm.pt fcum the Contmctar's
� � � -� Liccnsc I.�r�for thc foilowinr;rcncon/Scction 7031.5,
NE\V HOUSE SE`1+ER ,
� ' R:cr:nrss c-:J Pr fcssi�r..: CodrJ: dai' citY nr co«nty
mNN[einooiiiOvn� ir1•ic! r:�rJres a prrnrrt ro construat, a!ler, improre,
eon�iNc oq woeK . -_ . : - . . . . .
SEPiI[TANN,SEEP,FIT(5) ,,, �cr;tolisl.•,nr T:;e:r 4;;}•s7rree:ure,f�rior tn i!s iss++anec,
AND/02DFAINFIEID _ . . . __. CI�u re.7t:.' ; ().: a����ifa�.for s��CI fernsit to f1le a
CcssvoOt❑ DR`hYEll � � , , SiqRc�stctcn:c-t if a! bc rs liccasrd pars¢arst to tbc
� - � , � � f,rorisi�ns o�f1�^Contrcctor's Litcn.cr I.aa�(Cbcptcr 9
qtrea,uevae,s��[zoa � ' � (rom.rneuci:{;erid�Scctir,i: 7000J nJ Diztisinrc 9 nJ tl e
SELY.lGE CISGOS1l SYSTEM - � �
Pucinr« end f'r�y�-viona Cn,drl nr tl.ot bc i< rxcn:f�!
D'�SCONNECT PWG AND !�CTf fOf';d:::I II�C/:�':t.:f>r t!c a!lr,n,ed esrni(�tion.Any
ABANDO4 MOV�E 5'WE2 �
aneKviu5ea7iCinn:e5❑ . . ' . . r�iolctivn�S�c':or.7031.Sbyu�.�'ep'�liccr.tforaprrmit
s[P,ar.is�r❑ '��SSVOOLS O � - s1EJ:c:s tirc r.(�pliccrrt io a r'oil per.alry of no0 rnom tban
. � . � fia�c l�ar.dred da!i.xrs(SSOOJ.�
� - - ,--� - - ' � ' " ❑1,ns thc o�vacr nf chc propr:ty n•ill do thc n�ork,and
' � � . � ' thc scn�ctvrc is not intrnded ar offcrcd for s31c.
� �� � � - ' (.Src. 70¢4, £.asir.ess a:ou Pr fcssions Code: T!e Cna-
� - ' � � - - , lroctnr,'s I.iccr�r I.rr,�dacs not al;aly tn an ou•ncr of
. -. . .. . - , . properiy+<!•o LurLs or i�rpmres tticrcon,cnd u�bo docs
. __ , _ �, srocn u�or1: L�ir;�scl�`proaJdeJ thne sucl im(�rovementr
� ' .arr r.nt intrr,d::_'or n�crcd for sale.IJ, 1 ou•ecror, tbe
" � — - -- . � , � builJ:n? < se�rorrr.rnt is sold u.�itlin nnc yenr of
. � � - � � ' onn:pfetinn,� tbr, or.mcrvfirsi!dcr"�t�ill Gat�e tbe burden
. . .. . ' of provrr,,q tl at hr di::��ot duild or im/�ro:�c for 1be
_ - .. . . . - . . .. -� purfnsc n/salc./ .
I um e:ceeipt rnder Sec. ,
• � _ • f3 u P.C.;;r this reason �
. Datc �
— On•nnr
INSP£CTOR'S NOTES - �- ��
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