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1522A (8)
I ':r;'�iK�4� �":':'"%ti.�:.";�.::'.'.!�s:.'��,' .. . .„ . , , .. _. . .... _ ...�.. .. . .. . . . . ..,. , itierebv o.:... ..:.. .... .. .. :.........�.� �' :�:r'�r.... .:; r:.' . .. . . �j insure or(�rer�i(i:a'e ol Wo�kers"Compr.nsof:on Insuronce,a• '6n6a1D� - � � - , ,. _ f� a ce..c..-!�-_�.,,_.��...,��,o''Soc 3800,La6 C.i �Y o�e,cgy g•o., , . .. � � _.... .. . . �y.�p._- C ..7.�:�%?v:.;r fu.��s�eC --- � SEW'ERA S�EVYA E DIRS�POSAL PVL<;\,��i 1 :.:�:�panY_St.._�una.---- �., PE�MIT� . . . n��depar meN � 'fiied wirh���e coui�� ouiic�i n��ispecriar. COUNTY rJF�OS ANGELES BUI,L,DING Af�lD SAFETY . P v' . ., u.:;,;,.«<:-+�:w,:......,.....t. ,.�,.......,.n��....�,- .. ... . � �c:....,<f's.:..15>' ..... .�.... . . . . . . . ......w_.��....� . .,_,...9+.-...�...e.�F:,«...a.,v'�..+��: . '::�ax:.tii,:wh'.-......, ..; -.- ���°� $�20�85a�,p,«,n��r@e�,t� --- FOR APPLICl�NT TO�ILI f!d . . � CERTIFICATE OF EXEtie1PT� \ 4 � �RKET<5�' � ' ��" " � -��� ---��-- D ' . .,. ,., .,:.,.. tONNECTION ATA 3..D\v COMPENSATION 1,.4 ' :.cc�.cs��',�� �J£�=�y� f� __ �'^•�♦ � yA� �This sech, ,,... ....•.�,r....�•' , mvolvr.d cy!he 1_ permris � :-. � , :..�•. . '°�_�T�f�T�_'__"... va�-�o.a�[e[a:- . J. _.,., .L'.vv 1<crniy 1 .•.�• , :��...� of �e worK inr svhirh 'h�s �.rss�5r �j-��_��U��} mF,. , vE^ro� � .� �Gr,,:p�y� m n...N pe�mi'rs izvuea,!snn!I no:emnloy ony pe�son,n any�nonre�' ---- - - y "''F �' �"''.� . . . _ '- ._. ...,...... so ns'o nemr�e s.ibier�io r�+e VVorkers'Con:pr.nsalion Lnws �;.,,�,. ,�,��EN G�] ;r ,v:n�� ��;;,y�; )Q)�� . . . . ,. . .. .�. .�. PO �.JX 33�29 ._ 'x:`:<F�iti•"V^ 4C`l;:Ff2'f�\::• Dale_._. ApphcaiY . ��%Re:n ..� c _.. . .. ., . ........�... ' — . .. ... , -..f=?AV' ..i'.•�F' FASE':E��� R!�,^,R,^,•.N��\:.... _..'A....�N NOTICE TO A'FrP:�ICANi:�I., af;e, inak�ng r,�ti c��,����a�� ar ;.y glg�o,67_9gd�. Covina -F:.•; r..��mplo• yo. ..��,.. : . c•,. .��. •o the Wor�Ceri it: . ��! np�nsa �i�, �.:, � �, ; �, ,r you musi forrFw�th DESCR'iION �oruc '-fJ ..:n. . __. ., ., . ...._ ,�:,.._. ---��^ oR sr.wioe+uwG" ._ .. n I ��v i i s�cF DrUV S O s cr r s ' _,.� _,,_ �.. . py pernr, shail bc deemed �e�OierJ 3lD:k R.t;I f,J�T \TE ENCkOACi(AFENT ' 'ICF.NSED CON7RACTORS DECLARAilO!���� �o o:�n:.s� °:.Mrt No " __ _ �hereb ntfirn;•hot�cm C�ISPd undfv �Chootr.r '�Z�c `�� h:sr cr.:?• _ � . ,.,.....«._. y ��:. prn��sicns o ' v.'„ 9 jrommerrirq wnh�^••�- �.^�Q1 oF Drvision 3 0�thn Bus'- G.•�,:�35 �171 . Res � � �•��� x°�� .. .............. , :..s,uw.,> , .. .... .. :-nd:dS .. ......�...�. � .�...nr r.ess n�A P•ofessions f��r.� :r r-:!�cens•e n in ful�forr.e ond --- - ----- c�fert ,t .7 e�,seNumbe:.'_��`FSSI C34 ,-otir:�ti:r,-.� �'�LQG�.ST.__ ::;wec.-�.,.�:.ar..:« - - - } `" `"c'°t5_o/r�/��pL 822�BUe chwoad Dr. __ _ ` ,,..,�_,»µ, o � '- .1�DRESS O ��r�a.,kc:..�:\.F`� . .. cc�,r:oc�o•__S,r�c?inan nafe._�1(S�L�.52St_ ��q7Qm�.v 11-/_Z{.LY-,tY�'S.L.J Jlcl�'��n,^, ::G:`:.= •::.I' ._.. w..s.iC:�K:iE;a�w.i v :.Ii 'h •..;: ��y BK PG z �I am nxemo�under Snc_ ol�I•,�L.A.Co �:�'� 'Y/ $8? C�„5�ln.�j•F (/c� '� •, vv�:: F PlumbmgCodccnd'o.5ec.__ cfthe '�� i;5C4�PT�OtiC�s/OaK �tr . . ... :��.L. _ V ' -(:JS Sa�S:'���=^TiN�'(: Cq'h W 1 0 VALID TION ,a R 8 P.Code ior•nc�ol;ow:ng roason __ '. ''`>f'•-" —�--- ���'��_�'a- '...,"".^-. Z ' f �`.��._;�:nn,-�:-.. r-�i,—.:,n.<s � „u ��n �'SF 3�':a\i.r: � �}��•' I _ . .. �a!f .. .. _(1lC i:��N�'C ,J V� =k�r f�SP••yn �"'� , Sigro;ure-'__-' ...............,...........,... ,x,„aasn�v�r.4 �;-��c-'aq.:i.�Cr.R�;�ca Ja i ► OWNER-BUILDER DFCLARATION ^''4`""���.i`'":'k =�� �J C,G A. �efer::c>F:.,pG•.°_Jvnmf�rt� I he•r.6y offrm rhe'I om r.xrmpt from r'r�e Cornrocfor's License �x:�� i=Sc��. ec��.�.. ,e.n+�Cs: !aw`.or Ihc fo'lovnnq�eascn;Se:lcn%03�5,Bws�css and Pro- +'[a e-���n�2.�:n,:,�C.^,ti rG:sr �. � � c ! U ��ni0t�o�•sCode'� �r:.Fuox`;=esn tivsaa+ �� -r- -- — ( �.�2i.JrC !.os owne�of'nc uroperty,o�my emolcyP.r.s wrn wo�es ns � lhev sde rompensonon,will dc ihe work r.�o ihe s:ruc�u�e ry�.:J�u - �s::o��mendeq or oif�red fnr so:e.I,Sect:on 7044,B��s:ness permi} 5_�� y nnd Pro{essiors Cade• OWIVER'$ ���i 9"'�i b _ � ns ownr.•of•he prooer�y,�m oxr ., �•',; �;•; „rn•6 AUTHORIZATlON TOTAI FEE 2 • � IiCP.nStlC)C(Jrltrt)_:0�5't)CO^S'IU.1�:", ;:,',:". :::,�,'':' �'OE4 I HAVE A' 1:S l"->:�'�'Ra�' ' T:."�1'I��:�1:'vil�!\A•l:,^,:':':\'iAr�::4 ". g.i51f1C55 Ond P/�iC55�0l15 C�(IC' CONNECT�-F��]C iC:iC5f2i:iE.^.(%S•\'�-'!.f!.\"':'�I`�.IF�::�`:f2 CONSTRUCT�ON If.NDING AGE�vCY � '], �,�"'€- ► i �ic•eby cff�rm �no' �F.ere is a cn�s���<fior Iei�ding aar.nr,v -�'�f^1�+15 !-' � '�vyOF_ � y jor �ne oerf�rmance oi 7 r_ work For v�iv�n �h�; perm�t �s ?:����'�`��.�- �eyyl __-r-�yr�E„� n • ISSJCO jS2: .;C91.CIV C� � '� "�'� ] 1 �/ tendersName >;`•eyy ' � 'r� . �• • Ie i'�" .�l- Ler.der'sAddre.s . _,�.,<.. . .�...��. �.:..� ..��.�A.n. .s......,..--,... ..�.....:... ..... .... ...... �. ... .. . ... . a.� . _. ... ... � � � �cerl�rv �hnt I have rend '�,�s ap,�Lcahon �na s•o�e 'r�r tha �... aoove vr.orrr;or�on i;:orrn.c;.' .. „. . �• �-11 Counry .c-.��.,�,�, `:........ , oidi�nnces nnd Stale iows , . �•Snwers, and iie•eny ou'ho:�ie repre:... . . . . . Ir,enmr ��oo��the CtiOVC�0IP.N�OIiCL�DfOP(;flY tM�RSaPC�Of.��YFIOSER ��IL�'+(�' �`L�.V1P'�.(i^�+.^ fJ �1'.1_�__'� . . . $:an����r�P�ri•,�;�en �r.t� SEEREVFRSEFORE%PLANATORVLANGUAGE .. . .' . . . . ,., .......,�.::.:s�,,., .... .. , � . , ., . . . . .,.. , ,.,,. � "��. . �,. .�.. .. ,� �",�_ .�,.�«..r... ...,..�.,., .. � . .,. ,,.wy..__ .... . � . .�. : .,. ,. .�. ... ..,.. �. ...,,:•: •� . .,�:_ . . .. ... . . �� . . ...�:.: . , .....,.:::..`...._,..__.s..:....,....�.,... .�..w..�.•, . .�__.. . . ftusP�txO�'s�ES...___...___.....__.�.,..._ ��i'F.R-?3�PLL3��.;if;t::a,hd�A'FF��:�;; .�..,..,�,,,_,.,�'��=•s.m,� . ---_' ' .,,- •�. . . . ;.',:..... .-- -- APFR(�4'/'it"s '�TE �NSOEGfOR'SSIGNAIUkE� iwbrc&e�esa3�•..o.-,.r-n,s.i�•:�+.�'...^,c.,.r�a�tor'.c ---' .. �...._-'---'---_-'�. Y .�..- i.ieense Lawfar:he c:..,:.�+i;r.ra,,:;r.,:�,r�.in 71:i:.S. � . . 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