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1453A (8)
� WORKERS'COMPENSATION DKLARATION . � 1 hereby affirm thar I have a cerfificate of consent �o �elf insure,or'a cerli/icole of Workeri Companwtion Insurante,or �eneaao � � ��I PolecyfNo.`°7�851000SmPCny�S L C)p....d . CE80BIREV.I18]I APPLICATION FOR PERMIT , u ' ❑Cerlified copy is bereby fumished. - , SEWER - SEWAGE DISPOSAL . � �ceri�fied coPy�s filed wi�h�he counry building impecrion COUNTY OF LOS ANGELES BWLOING AND SAFETY departmen�.L � oo��p�Applitanl T Freeman FOR APPUCANT TO FILL IN CONNERION DATA . CERTIFICATE OF EXEMPTION FROM WORKERS' �iip� . COMPENSATION INSURANCE ' �oortEss stnna+ � o[rrN (This sectfon need not 6e compleied if the work involved by�he i�i�n, ��,E���� u�Q permit ii(or one hundred dollars�5100)or less.) � R I cer�i(y+ha�in rhe performonce of�he work for which this ¢p Sg sr_ fYPE���CT1ON �E'''Gr"F°o"� Y. CUR6 P.L. M.L TO P.t. pe/mi�is issued,1 shaYl nol employ any perwn in any manner (` so os lo bxome sub'ect to Ihe Workers'Com ensation Laws. /� °�'�� D 1i I P OWNER �dQYS �TZ� CO.IMG.NO. JO!NO. l Q ��� PO Bos- 329 TRUNK�fRMITNO. ROADPfRM1TNO. Doie � � App�icont ' �ooaess NOTICF TO ADP�ICANT: If, ofter mnkin this �ertifieoie of 6 � AFfiDAVIT WAI�Fq FASEMENf a�coao.�Nsra.r+o. w.re g CITY iEl NO. F��^ p�ion, .you shoold.become sobject �o the Workers' enso�ion prov�sions af the lebor code,you must forthwith ocscal�vrioni (OTNO. HWY.ORST.WIDEWNG c..� ply wifh such provisions or Ihis permit shall be deemad c revoked. � �ocK TGACT Vl S�AiFENC40�CHMENi �� IICENSED CONTRACiORS DECIARAiION w.or e�pcs. r[aMir r+o. I hereby offirm Ihot I om licensad under provisions of Chapler SizeOF�at Nowpr.tio7 9�commencing with Section 7000)of Division 3 of�he Busi- B iuion+c3 a�x,�s � ness ond Professions Code,and my licanze is in full force ond effe[i. pp e� /� �p.�}RA�LpR CONNECiIpry�HARGE FEE �iCMSQ 1`�Um(18I f��400 I Li[.��ass li� A��� �OOd REIMBURSEMFNT FE[ a COntIOCtN• Freeman �OIB 8/26/86 USY ya QQ�'d • TEl.NO. � SO� 2 DISfRICENO. GRWP B� IYWv � VWCESSEDBV V . sr..� uc. (J m ❑I am e:empt Under Sec, of the L.A.Co. u�Ng rap. 8 tteu �'D DFSCRIPTION pF WORK rEE � PlumbingCodeand/or5ec. o(tha FiNai �`f� b VA�IDATION � � �avs[s�wtR cor�+r.�er�r�ro 1 QQ onre %MLIC YKFR 8.&P.Code for�ha followinq reoson 5[WI�fANK.$EEI�([NI OQ F�r�Ai Z � P�iSAND/OiWAI1.�F�EID � - DOI! . r�IVAf p�R COn1NECTIM f0 BY . $Igl10�U1� Cp�NVECf/WITIONAt&DG.OR � i OWNER-BUIIDER DEQARATION �K 7a wu5[5[wtR ' . I aaow secv �i.oa�iNr�io ^1 4 5.3 A i I hereby offirm�ho��om exemp�from ihe Conirat�or's License EXiN.,�ESSPOOI.DRYKEIL NJINMIXE Law for the followinq reawn(Sec�on 7031.5,Buisness and Ro- iureR.rtevn�a at�enNoor�'aust � ons CodeJ: sewER oc asvo.w svsrtM u i +,e • • • � Q � �,os owner of the property,or my employees with woges os � their sole compenmtion,wiil do ihe work and the sfructure � • •2 7 5 Q is not imended or offered for sale(Sec�ion 701d,BuS(ness ' ond Professions Code). OWNER'S Permif S ]. � n� •2'],5�� ❑I,ai owner of the properry,om exclusiwely confrauing with AUTHORIZA710N TOTAL FEE Z Q n �J R licensed tontroctors to tonstr�ct the projacl�Seclion�O/4, _ 1 HAVE AT iNiS D4IE A CONTRACI WIM iME NEREIN NAMED COfJ1RACTOR i0 u�`O' r"� 9USinG55 OnfJ Pf0(BSSiOn3 COd@). CONNECf Mf ABOVE DFSCRiBED EX1571NG DWEILItJp 70 iHE%1&IC SEri'ER. CONSTRUCTION IENDING AGENCY , I 1lereby aNirm ihot lhere is a[onShVction lending agency �GNEDTHIS DAYOF 19 for the perlormance of ihe work for which this permil is �"�a� �� � ow�qs ac,cNT issued(Sec.3097,Civ.C.J. A�u Bz•Z • lender's Name Lendei s Addreas � . I cenify thar I have read ihia opplicotion and stofe thal�he � obove info.motion is carect.I ogree to eomply wiih all Go�n�y , i ordinantes and Stale lows iegulating Plumbi�g and Sawers, _ , and hereby outhorize representotives of this Counry fo enter - upon the obove-mentioned property for inspection purposes. �i�p�syc�iv d���i igno— �� ure o/Permilte8 Da�e fEE KVERSE FO�E7(►IANATOk/LAN6UAGE . , �n 1� y��". CC� 't _ � C t`ri '�1 V` C?•' C' '_+ � . . . . �:.�.a�v� �.� }� t�. ���� r �4 q(` T a%v �� ' . " q� (�1 G1 A 2S Q� v 'q ' Z `��� a: �iJ : O . �' . ' - c r �!, c�U �� 'l'U, . 1�„ . . . , , ;� \ ;�� `�1 `-� ?� !y�<i � G - " \� • , , ��n�.`�"c^`'.'" '.* ^^ `'. 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