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1591A
� WORNERS'COMPENSATION DECLARATION � � I hereby,affirm rhat I have o certifimte of consen� to self . .'insure,or a cerlificate of Workers'CompensoNon Insuronc ,pr � �6^a'°o - , PolcyNo�P �°�osm�ne°°� b C�EB081REV.8/BI) APPLICATION FOR PERMIT ❑Certified copy ti he�eby f�rn�shed. .S� SEWER - SEWAGE DISPOSAL � . ❑Ce�tified copy is filed with the counry building i�apecr�on COUNTY OF LOS ANGElES ..BUILDING-AND SAFETY ' ' de r�meM. - �� oare��Applicont �J� FOR APPLICANT TO FILL IN CONNECTION DATA � CERTIFICATE OF E%EMP710N FROM WORKERS' ��ioi� . ' COMVENSATION INSURANCE �wo2Ess i 5T'°Tior� o�v�H (This aedion need no1 be completed if the work involved by the h - MnNVKKE REFERENCE ' ��R permit i�for one hu��ed dollors(f100�or less.) ����TM � I�EARFST iYPE Of CONNEC(IpN ,�N(d}H FROM �cerffy�ho�in�rhe performonce of�be wo:k fo:which�his cRosssT. -S y �q8 p� � M�7pp� � permit is issued,1 sholl not employ ony penon in ony monner ' p�� ao os to become su6jec�to the Wor4ers'Compenwiion Lawa. p�Eq �o.�,,w.r,q. . ���. � ��� iRUNK PFRMIT NO. RO�D PEPMIT Np, ' Dote Applicanf � appREu NOTICE TO APPLICANT: if, afrer making this Cer�ifimte of ���, - ��� A�IDAVIT WANER eas�mpNi RFCORD.�NSTB.NO. D/.iE � �ption, you should become subjecl lo rhe Workeri iF�i , pensafion provisions of the Labor code,you must forthwith oescaivrqnl toi�+o. Hwr.pq5t.wioFN�vG cvmply wi�h such provisions or this permit shail 6e deemed � IeVOked, ' &OCK TRA[T S7AiE ENCROaCHMEM NO. &DGS. PfRMR NO. LICENSED CONTRACTORS DECLARATION srzt or ior raow on ior � � I here6y affirm that 1 am liceneed under provisions of Chop�er �� ' �9(comme�cing wi�h Section 7000)of Division 3 of fhe Busi- euqom�s QIARGES � ness and Rofessions Code,and my litense it in full force ond � effecl. - cONroAC10R Conx�Ecr�O�+OfnRGEfEE y /�(�� 6. Llcense Number,�Z"!A d Lit,Class ,�pq�Eu ��M EIMBURSFAAENT FEE 0 . /�� / I1 DiSIRIR Np. GROVv MAV PROCESSEO BY V Coni10C1ofT�K�/ �OiB C11Y TEl.NO. '7�' BK PG Z � ❑I am ezempt under$ec, �of Ihe L.A.Co. _ ����p�p y aAu C � . � PlumbingCodeand/or5ec. of�he "'�� �EKRiPT10NOFWORK r[e FiNA`' W � Hous�s�wea cor�r�ccr�r.�e ro DATE Z„�� VAUDATION H Puuic sEwec Z B.8 P.Code for the following reason - gpti�T,vu,SE�ppG�yit pR FiNAt virs�woiar ow�ro�io � Do�e �ouse sewea ca+r+Ecnue ro BY ' ' iRNAif O�SVOYLL S�STEM . Signafure ' mriH[Ct wortq�,u 9ipG.pa � . ' OWNER•BUII�ER DKLARATION '��r°�+°�5�s�v''E° ' 1 here6y affirm tha�1 am exempl from Ihe Confractor's Ucense E�%TN.,�OCESRIVOL,ppv��WEt�I,"Nfl�EµKKE , �^w for�he follvwing reason(Secton 7031.5,Buisness ond P�o- ntiE4,aevwia pt�Bnappn HWSE � � �'0�5 CO[Je�: ' SEWE4 OR DISPOSAL SYSiEM , . V� n I,as owner of�hw preperty,er my err.plcyees with wages as �' �, � their sole compensotion,will do the work ond ihe s�r�Uure �{e s 8'a j Q ' is not intended or offerad for wle(Setlion 70A4,8usiness and Professions Code). OWNER'S Permit S �(y (y I e e 2 7,Jr Q ❑I,os ownar of�he property,am e.cl�sively coM�acting wi�h AUTHORIZATION TOTAL FEE Z Q licensed coMractors b constrvcf the projecl(Setlion 70d4, I HAVE AT 7H15 DATE A CONTRACi Wi7M T1E HEREIN NAMED CONTRACTOR f0 m"t G 7.Jr l�c=i 8usiness and Professions Code). caarvecr rr�neove oescRieeo Fxisn�c owexur�c ia rH[rueuc sEw[c. /// CONSTRUCTION LENDING AGENCY ' � � ► O�I]�"8 G I hereby affirm that Ihere is a construction lending agency SIGNEDTHIS DAYOF 1 for the performante of �he work for which this permit is �NFR� (�jf/�./ OWNF4S AGFNT issued(Sec.3097,Civ.C.). A��ss Lender's Nome lender's.4ddress " � ' � 1 terlify that I have read fhis applitarion and s�ole that the � � above info�ma�ion is correct.I agree ro mmply wi�h all Counly � ' ordinonces and State lows regulaling Plumbing and Sewers, . � ond hereby authorize reprasen�atives of this County fo aMer . � � upon Ihe obove•mentfoned propeny for inapection purposes. - . ��`�i�vmeu�i�: _Q--�—�-�, Signotureo Permitlee Date � SFEREYERSEfONE%PLANATORYLANGUAGE � � " �g f . . � s �a ���� � � . . ` o�� ��3� � ���� -�� 0 ���- � O , O�,�c��� o��� 7Gsr M � Np � � � � �.�,��� �$ � �'. :.�� , . �° o � ��- � � ° � � ,., � , �� � . . . . � °� -. � , �� • �, , . � o � .� � . . N . .. . . ,_ ., . ,,.�. : :. ,�1 • ../ . r� . •'� . � � •.. ,,. . ! ,f . • i� ' ' � . � •` I � N ` 'J • • ' . � � ' - N . . ' . �. . . . • � ' �• , r i , \ • . ' " `� ' \` ' '. f.. /". \ � ���ry�. ' •�^'`x��?l�r,*'��� ;.� . 0 o Y o E� , ���'�� � .� �. °�. K , . . • N y��� R�•P p� S�j�Q � 9� �. � �. 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