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,.LKERS'COMYENSATION DECLARATION 78A842D � �
,
_ ., �EBoe,,.eo, APPLICATIOIV FOR PERMIT ,
1 u2re6y affirm that I have a certificate of consent to.eu . SEWER-SEWA�GE DISPOSAL p
insure,or a certifiu(e ol Workers'Compensation Insurance,or - � �
a certiFied coor thercof(Sec.3soo.Lab.C.) � COUNTY OF LOS ANGELES BUILDING AND SAFETY
I Poiicy No. Company
FOR APPLICANT TO FILL IN CONNECTION DATA
� Certified copy is herehy furnished. �
�YILDING f� t� STATION D6PTM
� Cerlified copy is filed with the county building Inspeclion _ •ooasse ��y � W� y u�ren �
department. � wcwurv 7 (� rwnNo�c FiFiN6NC6 �owew '
Dafe Applicant r�eweear TYP6 oc connacnon LEHGTM FXOM
CERTIFICATE OF EJCEMPTION FROM WORKF:RS' �Roes sr. r. cune ..�, w.a.,ro..�. '
COMPENSATION INSURANCE M�$�� � i � P•���o•
pWN6R CO.IMV.Np, lOB NO.
(This section need not be compIeteA it the work involved Mw" .�� �I O W`L/j �
ADORHS! TRUHK�CRMIT NO. ROAO PCRMIT NO. �. -
by [he permit is for om hundcod dollara (5100)or less.) � F�,p.�� �� u�4M q �oqo �w�ra � p�rQ a
�rr.�ss NG'L�STg�..,o.� 3 59'�'7 . . o
1 cerlify that in the performance of the work for which this �e¢w� � V .
permit is iasueJ,1 shall not empioy any peraon In any manner DElCRVTION LOT NO. pyyY.Op 3T.WIDlNING � ��
so as to become subject to the Workerc'Compensation Lewe. �
�e +s��. B�OCK� THI�CT {�nT6 tMCNOACMM6NT �—
Dale �z'�'�TPplicant �w�s' NO.000tD6II. rlRMITNO. (� .
NOTICE TO APPLICANT:lf,after making th Certificate of size or�or now on�or � .
Exemption, You shouid become subject to the Workers' uee o. s�Rv�e�s�gT r a r� c�wnees L �
Compensallon pmvixions of the Lebor Code,ynu must forth- eui�o�nas _ .
wifh compiy with such provisions or this permit thall be s��i/ ' C�' �7� �� �onnacT�on cnwwes Fsc
conrnwcrow
deemed reroked. - ,
LICENSED CONTRACTORS DECLARATION woowsss ��OO C'� � '� L ' R6IMBURfCMHNT FH6 '.
I hereby atfvm that I am Iicrosed under provtsions of Chepter �bO��d��� 5 r d� "•�c.. .ou r+w. ..oeesaee�. �..
CITY SL.MO � . �� o
9(wmmencing with Section 1000}of Division�3 of the Busi- � " � �
ness and Professions Code,and my license is in full force and - erwre q ,�1l,Qj _ �ic. p �� //�i
e�.�. . . ��cense no.R�M�Y/ c��ss ` ��
n0. Ol9CNIPTION OP WORK FEe FINAL
.�..w�o..��.,. ,o _ , VALIDATION
License Number��Lic.Class e � :u':�•.w.. - �� O�9 OATE `��-��� ��c
�PD�-�t� 9--Z .�.,,�,,,��o.�..,,�..,.e. '
�Contractor ,�e ^�''6 ��*••�°,�• •.,«•,°�° FINAL
—� ouse s w CowwCCr�HG ro BY `�v
� 1 am exempt from the licensing rcquirements as 1 am o `,o� .
licensed architect or a registered protessional engineer :w`sa"
acting in my professional caDacity (Section 7951, Bus-
iness and Rofessiont Code). *��e�sca`o`o�` :���, �«o
��ew,we�w�w ow wewxoer«e�se�
Lic,or Reg.No. Date �
f15fl0A
I�IOME OR'NER•BUILDER DECLARATION .
n�• r y � Q
I hereby affirm tha[ 1 am ezemot from fhe Contrector's OY1�I�ER�S Permit t O '
License Law for the following reason (Section 7031.5,eusi- AUTHORIZATION TOTAL FEE r� 7 .lr0 � ' •2 Z 5 0 '
ness and Profeasions Code): ,,,,,,�.r,,,, o,,,� ,,.cr«ir«r.......a...r...eo cow- - �
� 1, as nwner of the property,wili do tAe work and[he *o r�e:usue sew�w. •wiov.e.scwuso cx�+.�«�o • a o�'],F Q�
atructure is not intended or oPfered for sale (3ection SIGNED THIS DAY OF is � �,.J�'�'Z..8(�
7044,Buaineu and Professinns Code). — ' •
CONSTRUCTION LrNDING AGENCY NeR��G� �
I hereby affirm that there is a construcHon iending agency -
for the performance of the work fur which this permil is �
iuued(Sec.3097,Civ.CJ. � .
LenJnr'S Name
Lender's Address
I certity that f�have read this applicetion and state thal the �
above iniormation is correct.1 agree to compiy with ap Cvurty � �
ordinances and State laws regula[ing Plumbing and Sewers, - �
and hereby authorixe representetives of this County tn enter �
uD�n the above-mentioned property for inspection purposes. - -
���: ���` �`. SEE REVERSE FOR EXPLANATORY-LANGUAGF.
Signeture of Permi ee �ste
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