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. .. _ _ _. . � NC�RKERS'COMPENSATION DECLARAFION - - - � -- - -- - � � � � � � q 1 he`reby a�rm that 1 have o certifimte vi corisent ro salf �� - � - � -� - - -- �� insure,or a certificate of Workeri Compensmion Insur6nce,or ��`6'�0 - � - - � �-� o cer�ified copy rhereof(Sec.'3800._�ab�..,. .. �E�,°EV.8,8,��.. . . . -� APPLICA�ION� �OR�PERMtT � Policy No. � Company �s. C,A,C p C - ❑Certifiedcopyisherebyfurn{shed. � .' . . .��.-�.� � ...-'"SGfI![.FN,' SpW�GE�DISP45AL.:...:. . .-.-. . .--. - ._. COUNTY dP LO$ANGELES, BUILI)ING.AND SAFETY - �Certified copy i�filed w�th the county building inspection . �� � � , . . , � . � - deparfinent. � oare npalicartit �OR APPLICAI�lT TO F11L IN- -. ':'. CONNECTION DATA . '_ '' _ ... - � CERTIFIfATE OF-EXEMPTION�FROM WORKERS � eui�oirKK -� ---� � ---� �- -- � � � - � -� � � - --COMVENSdfkON INSt1RANCE-"'., .. . - aso2[ss �- �` . Q�a-. . - STpt�ori . _ �rrH ... .. • (This section-need not,be compieted if�thQ work invakved by the i�i�n,..' � �.N�--- - . . l.j nnaw�ae a�ecNce � a�R permit ie for one hundred dotfara(S�E10)ar less.) � � �� � � � Tvae oF cor�NEcnoN �� � -����" NEARESi -1 IENGTH FFOM I cerrify ttwt in the performonce"of the work for�which th�a caosssT.� �e f Ed--� � I�ZIIV� ' � V. CURB P.L M.LTOV.I. � � permit is iswed,t ihalt�nat amployany pecson.ia�any manner. .. ___... .�._._...._ .__..�_._ _.._:. . . .. __ . .. .. ..._ . ... .... .�.._ _._. .__._. ___. __.. ..P.C.NO,..__.. so as ro become subject io ihe Workers'Compensation Laws. pW�R N G G / oo.i�v.rao. ioe No- � � . .. � �.� . . � AODRE55 • S. [/t^R�FiA W�f� TRI/NK PFRMIi NO. R0�10 PEItMR NO, Date ApplitAnt. . .... .... ..... . ..... . . . .....' AFFIOAViT' WAIVER EASEMENT GECDRD.INSTR.NO. OATE � NOTfCE TO�APPLiCANT: If, ofier.moking this Certificate of �ir� . �y�rA �t.pp. / Q�j/-o!J S� Eaemption,� you ehould become subject. to the Workers' �� Compensafion provisions of the labor coda,you musl forfhwifh pEscpipnpp� lOT NO. HWY.OR 57.WIDENING comply wiTfi�such-proGisions o��tfiis-permH shall be deemed ��al/z IGVOIt@CI. BIOCK TRACT STATE ENCFOACHMENT �LICENSED CONTRACfORS DECLARATION N'l.OF&DGS. ���T�' 1 hereby oHirm thot t am licensed under provisions of Chapter s��iot How aa ior 9(cammencing with Section 7000}of��ivi�fon�3 of the 9usi- au�itmv�s- o+�a�es ness und Professions Code,and my license is in futl force and effeC}. [pNTPACIOR CANNECTION CHARGE FfE � � Li[ense Num6er Li[.C�oss qppqEu RFMBURSEMENT FEE 0 DISiRICT NO. GROUP MAP PROCESSE�BY V Con>racior � Date CITY TEI.NO. Z ❑I om exempt under Sec. � of the L.A.Co. �i¢nisE rro, cu,ss `p �_ 6 Z O n�s[ PlumbingCodeandiorSec. offhe �� DESCRIP710NOFWORK r� F��i rJ 78iK5�EW�ER��NECFINGTp DAiE C����u.��� VALIDAFtON � � B.&P.Code for the following reason �vric TAruc.S�EPAc�v�F oz �� Z PRS ANO/OR�RAINf1EL0 .n t� � DOfC FIIX15E$EWER CONNECiING TO �� J ' � PRIVI.TE DISPOSAL SYSIEM Signpture CONNE[i AODITIONAt BIOG.OG OWNER-BUILDFR�ECLARATIDN W�'��sesewev ----_. OVERFLOW SEEPAGE GIT,DRAINFIEIP � t hereby offirm ihot I om exempt fram the Confrvttor's litense � � - cxrrv.,�ssaoa�,arsrwnr;�marv'ro�e- �� ��� �� �� - �--/ � ��� --�- �� � Law for the following reason(Seclon�D31.5,Bu�sness and Pro- ��R aR oisrosnt svS�m�sE lJ--��-�� �� ���- � fessions Code): C I,us owner of ihe properfy,or my employees wilh woges as 'aP"'Q� '� � �� {�', their sole mmpensofion,will do the work and the sfr�ci�re �� � - � 4'f7-- � � is not intended or offered for sole(Sedion 7044,Business �{a e � e � [j and Profess�ons Code). OWNER'S Permit S p �'1� ❑I,as awner of the proparry,am exdusi�ely conrracting with AUTHORIZATION TOTAL fEE f2� � 's c I,v(i II[BnSed[onffpctal5,f,0 COn¢iN[f tllC PlO�E[t(S2[�IOII JOM, �HAYF AT THIS�ATE A[pNtRACT W,ITM iME,HEREIN,NAMEO CONTRACfOR TO .a ,� 5 4;`��,_ . BUSiftESS and PIOfa35iOM COlJCJ. CONNEC!THE A90YE OESCfl19EU FXISTING BWEUlNG SO TNE�U&K SEN'ER. 'b L .. �U CON5TRUCTION tEN�ING AGENCY � � � � - � �--- G�/.��4`��,C 1 here6y affirm Ihat there is a construUlon lending agency SIGNED THIS DaV OF 19_ - far the performance of the work for which lhis permit is �,�,�R aGENi � issued(Sec.3097,Civ.C.). AD�GE55 Lender's Name . . . . . .... .. . . . . . . tender i Address � �� � �� ( I cenify�hm 1 have reod this applimtion and s�ate thai tha � above infarmation is corcect.1 agree fo comply with all Counry � � ordinantea and State laws�regvla�ing Plumbing and Sewars, - � - - and hereby autharize representati��e5 Of}his Counly to eMer � � � � � �� � � upan the above-men' ed plap 'y for inspettion purposes. /, =v��� - �. Signat Permiftee. ate� SEEREVERSEPORE%PLANATORYIANGUAGE � . _ *�, .�• • ,�� ,� ,.�; -����� � ��� � -�� t . '. m �» C « y ,$ �, �• Z �a� ��'��M� ��� � '�� 3� ",� . �s� � '�`�C� '�o.�.. d�M^ �p �� � �. � �. �` �M 4�� �r� �W�fi��Q���� ' ' ' _ . �� ��� � � � ti � •�y� . � �� . ' �� � � � .. �. � � � � ��Y ��� V ,� c��� o�s��� ��o '��� $ � . �+.� � �� � � ,e .��» � A �� � �, ���.�.�,��� � �, ��.. � ,� � �a� ���� ��������s ���� � � . �� � „��. �„��.� �.'� �.� � . A ��� ��,g���� � �g�� • �, �-� �' �« . � �M�� ,.�:���• �$p����� �'��� t? �. ' . t � � g�r'�.�«� �� 6 ,�$�� g �,�, � p� � . - pG ��•�.x � ��'�',°�T�°��'S$����a g �� ��� m � o�! Q � � .ei «� € ~ H� ��s''�,�. "" � g � �� ��'���^ �''R � ���, � . �O � ��yM,0 �� ���O��Q�H��� � Fi ~ �� ?��.� �'{��'��� Y� , . M � � � � ,.� i � � 6 �, � � � , � � , � 6 . :. N �+ � `1"' O ?` � � d � ! o � Q � . 1 .� � . a � � � � � � 9. � .r . � .. � .� � � � , � �� � , � .. � � � . . � � .�� , W w � , ' � � , � z 2 & � V W � � O � � v � �� � � � Y �o � aN ���� a � �� �`� o �� �� �� d � ��� �� Z�LL� � < �b '� �� �Sa Cf 7� � ��