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1524A (8)
.. ........ ....... .. .. . -- .�. ... ... . .. . . _. . _...._ . WORKERS'COMPENSATION OF.t[ARAi10N � � � ������ ����� - I hereby afiirm �nn' � haae a <erti4�ra!e of wnsen! 'o sel! . . �, . � � . � � �nsure.or n wrr:6cate nf Wo•Keri Co:-�oensa!ion Insurnnc�,ar - �enaao a«�.�t��d copy rhereor(Se<.3800,!ab�.�, ������ ��� ���� �pp���q�OptV �OR PERMIT P�'..^'--�?'r,,...:::,�, ..5-�..__r�and - -— s �.^;,...,,,7!��"��,/,�;• :.��,�5ti�a SEWER - SEWAGE DISPOSAL ��Ce.iifie�cr,py�s+�a�d wdh�ne roiimy boudn�� nspecl�on COUNTY E7F LOS ANGELE$ BUILDING AND SAfETY dvporlrncr• � ..,.�...,.:....,r..i......, ; . �.,. . 82� 5 ._. . . _. . , .:...... .. ., , Darc_ _.�_1._�+ooi,ram_._Fr28ID3ri . FOR APPLICANT TO Flli IN ,.�- ^�M�,�� M1� . CERTiFICATE�OF EXE1JMpTIO�f�FROOM WORKERS' Y. , ��,, �,, ��..�-����'.��,";`•�•�"..°•��.. .."�..,• `h ION DATA.... ..M. �. CONNECT C:OMPENSATION INSL'RANCE ar:^ir:s� � Ky�; i ��� ;Tk:is sec',on need^ei be+cumplc:teo:f;nr.work�nan:ved b he �-- -- �� . ��'.: �+���W -� �n v;.�.q'�kFfFtf•' '_-'._.. perma;s for one tiunnred dollars�S1C0'or letis;• ��"" ' �.�11��1_-. .—.- _.�._ ,r � <erdy �•;a; in ;he per�ormar;c o1 �he work ior w��ch•his vrn.i=' � �j � i�,.�:._.. ....'_ """""_ _ ^..c+� _e_'�- .:o�ss- �G6�Cli.�_ . . .: ne��r�t is�ssoed.:snaJl no�emo�oY�ny person,n nr,y.aa��ner �� r...' .. ' .. .,- _ _,. . ....� .... .......... so ns'o bewme suh�ec!lo'nr.Workers'Coi�pn�aanon�a•�,.,. .,. fINDEY GRP "� ��% � . ...v�t . ,....... ........... ... �o���v nc r,:r,.o d,Z�c� - - .. . ... _ . ,,::.,. /� 7, DO'C___—'AP�IiCC��lr__ . �":f.4�_`. _�O BLX_J329 _ "4..\K[i�1.5�:nC iCA:P�R'�"V(? .-_� . .. . . At . . .._.. ......... . ... _ . � :����J�•.•' Ir'.P�JFk �...•::\I t=:^R�1 ViT3�:; �4'.'<. NOTICE TO ApPIICAN?�:�i�,��ni'er rraicing �n�s Cerl:firatc cf COvlll`d '� �;� 8�,���=i[15 l .,,f,��impnon you should become sub!ect to Ih:c Workers' �ror,. �. ' �+pensohor.provisinns o'ihe ' you mcs'{Orfhwdll .ti^�iip:�p�� iCf V,^, �ORST.WIDENiNG np�y wi:h such provnio�s oi shr.h oc deemed �- '-- �.... . •C�OkCtl 5^::k 'RFiI ����.____ ' , '-_\C�20��.'rlUsn,' !ICFNSED CONTRACTORS UECI ARA?;ON �=;e;°cc5 ''''"'`�c � a,,,. I F.nref; affirm�hm I cm Ir,ensed under �� �:'o�..:� „ Nc:�CN�^' y provision.ni C opter „_ ' 9 ;:or�mer,uny w,�h Sec'�o.:7COC1 of Dwisior 3 0�•'re 3usi 4,�i,.�:-5 J1YL Res• ;14Z:,FS „ ���µ� neu ond P•ofnssro�s Code.,ona my ucense ix m�uli force and � � - - efie<! �7 A p ry'JA ::���4aCi,^.a i�RE�i'TAR�CON�Ti c;;v,•^,r,.�;.-•�;_�-.-. ' . _ Y Li:CnSCn'urnbl�_'t�`Y�V� _.l�C C�(i55__4L`L .':Dk:c: -- ,7'.• .2}t:nc!�iFiC'• • ' ". . � p� ' —��..G_�$G�C�LW2t�St_L��_ _ ......_.�..... u :onrrector�BQcIA�-_Da'e__�ZO�S25�L_._ ^�� � �(}o N,^ 72::1� ... y�Y::iS:L�3• .• ���Y�.ta_Loma �� I.:: (14/ZG � � `�/ i '< , PG O �_i ��m exenn�under Sec o%'he L.A ;o. Srn;[ ��a �J -- �:...�:.� 474887 ,.,,< C Y � � � n:' ^E5:R.-T..^.�:0"JvOR�C ,;. Pl;,mb•r.qCodeard br5ec'.,___, cfrhe ' __ �• - " � .,. , . —' ' V . _ . ��aa. ..t...':�:,yFt4:R C(:��E^V�':: �... .� 9 8 P Coae ior'he fullow�ng�cuscn__,_ P1',�y'•"� .. . ..� 7_I�p ,.,: �p_2�j_ VALIDATION �.�..._.,..,.,,y -_ —}�.:"'*A�< 5'�PAGf F'^.4 f" � I � . .�ale �r"_:,\._..a.)iAIN=r�j r:nP _ '__—__ '_'1 "'i.fF�:C�':�E:'�i-C ;v _��V5 iT� ' ,>���::�� � Signa!ure___-_" .. . .. ...............„.... .�.. , —-1.-rih=.=�;.."a��.�•�i:3.��:.< -�� _- '—_ � OWNER-BU::DER DEC!ARATI�L ' . .. �.� :�;4k'T':;�'".�:,�`Fn�<< :'.•��o.v sr.-:.�.;s r- �+n��-,� !hereby niiirm ihr.�I am.exemp:�rom riic C^.....::..:.�,,. . :r,rv ;p;<cr_,• r.v.�i_i .�.n�-�Cir. ,.... ' Law�fcr rhe follcwn,g reason�Secto�7031.t :: .. �. ��. . . n rR r�E,:�C�N� f" . >�ons Codo': ... ,��c•�, . .. ... n�-r. --+'w;oyn. ....� a.! J�4' i,as owner of;qc properry,or my employees w��h wnges os r.�,o ,., � '� ;J •he r sole rompensotion,will do the work and tha s'ruc'ure s no' � ����::,•�.:or offered for sale(Secrion 7044,Bosinets � ' e� � n��d• .�,�, : ,,Code1. OWNER'S Permrt si �-�� t r L L 5� r'I,os owner of thc prooer;y om ex;lus�vely co��'rr.u�ao wit� AVTHORIZA7I�N TaTAI FE� �G7�S v - � ^%�" i.vO u IirenSed ron��ac�ors lo ronsh;�[':he Proler���59:!io^7044 .�•T:r;.*�.••� :•C i.r„4'u,;;r:.'r 7•�[i•�Rf.�n:��•er.�:::e!.!:.";i;'_� :, .� Business and Profns.5ion=Cnde' r_c�np^u.=n_��^:f5::��r,px 5'�nc�a�[. �G 1�:rd=c;..';�:::u ii�:i.L�/""G'b . CONS?RUCTIAN!FND�NGAGENCY � � ��� p_ , I hereby efCrm �hn' 'hr.re n c cons+oc'ion :endmr ogency �!G\%J�FPS �"� DA'+Or eT 'q� b• the Der'ormonce o+ Ihe w�rk �o� wni�h �4is penrii; is �'���-���` .ssued(Se�.3097.Gv.:j. ` :.�,re:,:.==�i_�-_ � f:..r �ccrs;... � s . , . !ende�'s tiamc �- "-" ' � � ' �' lender'aAdr.'re,s � _..� ........:..:....t..:w,s�o.<.-.a,.,e,.,_�::..:;wa..�.ren,a�m:x,c-.„:.,�....��,a.a:�-�•.:.�<.�:.�..:::...:,.•_.n,,,�::.s.�...,.,....,:::..�.:..:........._�.,..........,,:,..,.......,...,...._.._....., ...,_. .' ceri�fy•n�i' ' nave reatl :ni�nupiicn'ior nnd s�a'e �ha� �he '.... abVVE`�ii�(IffFl(SI�On�S CCnCC' I(]G�CI;'O:f)TO;y����•l O��COU:I�y crdma�ces m,t7 Sto:c i�ws.agalo�r+y Fl�mbing ona Sewcrs and here6y ou�f:onve represen�n��ve+or���s Cnun+y ro en•er upon'hc/a�ov:�-me��+�oned propar•y`.or�nauer!ion puroo•se.x ��}�-�J' i ,�= J �d� r��� �:. Sig;cr�re o,��rin�il;pi� pp�E. SEE REVERSE FOR EXPLANATGRY LANGUAGE It�63PE:4AR'S dNOT�� �������� +,"r�?V:°a'FR-I�.JI��,11i18 l31�.C�.r"aR�s��''.kv �,.:.,.,:.�...�..�. . �.,�,. - A�'�'RG�JA�s: -__oa:: iNsrE�oa�sv�aTue.��! -------�.._._. T..___._....---- --- ;:�rirb,atil`iur..:'..a::2aa�:kapef;o�r�ti...•C::.yxY�z�t.cx':s -- _.—..---•�--------'—� i.ic�rr.e i�c:'•'c:L:a i�7�.v?r.�,:c�.n/S.scti�R:i^3F.3. new vo�se sevuee I •--._� ,—--'- �eesinesa: t.�d Prufessiase�s Cadx):Any czty cr.�n:.3s• CANNECT.IODI`IONAI � - —'-------�------�--------�----- - wbix�i regnires o permit ta corutrucs,g6ee.,,bmprava, �6�.mr,i�:c oc v1oRx �,_ d:r:::::Tr":;��ir:*¢a:: ' ... , .... . .,.;is;u¢vsc�¢, �SF.PT�C'ANK.SEFP.PiT(51' '�'� ' ' ' �.��: !�+�:,y..!. .. . ���'Cy'ni,j .. ...: 20 ffT@ 6 ' AkD/nRDiAINtiElv ._, . . Cit+..:��i �::.�:.:'.v�!" :ihl. '." ..:.�8'EC893s�1�fld4PSk°A98C fb 2fJ8 �_ �""�_ eESs^a�:❑ nay:vH:�l � � . '.. . .. ... . . . • .. . ,. 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