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1463A (13)
WORKERS'COMPENSATION DECIARATION � 1 hereby offirm �hot I hove o certifico�e of consen� fo salf y'� imurc,or o'tertifico�e of Workers'Compensotion Insurance,or ]dAdRD �I Pol c„IfNo.`��rh1O�omC 3�STi:`�'Funa �E809IREV.VBL qpp��CATION FOR PERMIT . . " Y �— P��Y ❑CerliFied copy ie hereby(urnishpd. - SEWER - SEWAGE DISPOSAL i �Cerii/ied copy is filed wt�h�he womy building��:pecuon COUNTY OF lOS ANGELES BUILDING AND SAFETY , department. �� � � � �oro.�/�Le6aPPu�o��_.T. Freeman FOR APPLICANT TO FILL IN CONNECTION DATA � . , CERTIfICATE OF EREMF7ION FROM WORKERS' emioirac . COMCENSATION INSURANCE A�OFF55 5T°''io� �°rH (ihis section need not be completed if tha work involvad by the ��ircY M4NHp1E NEGERFNCI uwta permit is ior one hvndred dollars(SI00)or less.) � R I cerfify�hot in��he perfo�mance of the work(or which Ihis cvosssr. iYr�a�aw�cTar� ��TMF� Y. NRB P 4 M l.f0 p.t. permii is issued,I sholl not employ any person in any monner P:�� so aa fo become subjaU�o�he Worke�s'Compensotion Lows. pwN[a Anden G co.v.w.rq. �oe r+o. �7. �I` PO BOA•• 2 TRI/NKPFRMITNO. ROADPERMITNp. Date APOlitonl � aooa[Ss NOTICE;TO�APPLICANT: If� Oftef moking �h15 CGriifl[oi! OF ��TY AFfi0.4VIT WnIVFR EASEMfM RECORD.INSiR.NO. DniE _� �ption, yau should become sobject to rhe worken' COO�I18 r¢i.uo-818 6 � I ensofion rovisions of the lobor code, ou must forrhwith �EGAI P Y OESCRIPTION IOTNO. HWy.pRSi.NnOENING comply with such provisions or this permil sholl be daemed C IlVOItQd. � � BIOCK iRA�T p S7AiE ENCROACHA+EN7 � ��� LI�ENSED CONTRACTORS OECtARATION w a&o�s v�aMrt"°. SIIE OF lOT NOw ON LOT I hereby alfi�m�lhol I om licenaed under provisions of Cboplar 9(commencing with Secfion 7000)of Division 3 of the Busi• �gu�iip�r+Gs .S� • R8B• p��ac,[5 ness ond Professions Code,ond my license is in fu0 force ond - eSfsff. r� � �pNiRACfpR CONNECTION CHARGE f{E License Number 41 Q887 �i�.��ai5 ��� ADOYFSS �22 Beechrrood QE�MBURSEMEM FEE r �omroao.T. FT@eID£1II Doie 8/26/86 c�i:AltB Om rE�.r.�o o�s,a�a�+o. c.�a� ,.v,P wocessEoe. O ��'��. as ���. _ 1� � � � I om exempl under Sec. of Ihe L.A.Co. npu � N0. �ESCRIPTIONOF WORK FFE � PlombingCodeond/orSee. ofthe viHni �� O NOVSE SFWER COMNECTING TO �v oarE Z�� VALIDATION v vVDllC YwfR B.8 P.Code for the iollowing reason 5[iIC T�Nc, VAGE NT pR d P�T$ANO/OR DRAINFiFLD FINP.I N Da�a wus�s�w[R cor+r.�ciinc ro ar Z VRN41E DI50.7 YSiEM _ � S19t101Ufe ' . CONNECI pDD17idVAl&DG.OR � OWNER-BUIIDER DECIARATION �K to r+ous[5[wca � pV[QFIOW SEEP�G[PIT.ORA�NF�FID I hareby affirm tha�I am ecemp�from Ihe Confroc�or's licanse EXLN..CESSPQOL,ORYWFLt.MANHIXE . low for the following roason(Sec�on 7031.5,Buisness ond Pro- u�[a,ctrnrte oa ae,�NpoN Mous[ `� Q(z 3 A �Ian3 COdC�' SEM�FR OR DISPOSAL SYSIEM ,��•�,as owner of the property,or my empioyees wi�h woges os . ir� � • • •I U thr4 so!e mmpsr.sa!ion,wil!do Ihe work and ine srrotture � � � is not imended or offered for wle(Sadion 7044,Business � � <•e 2�,Jr� � ond Professions Code). OWNER'S Permit f � ❑I,as owner of�he properry,am exclusively�ont�aU�ng wirh AUTHORIZATION TOTAL FEE � � `• •2 7 5�� � IICOIISl�COl11fO�t0r5 10 CO�S1fU[f tf1C pf0�![I�SB[�10��OAA, 1 HAYE Ai TNI$DATE A CONTRA�(WIiX iHE IIEREIN NAME�CONtRA[TpR f0 0$.2 9—8 6 I BUSInlSS 011d PIOfBSSiOnS CodCJ. CONNECT THE ABOVE�ESCRiB[D ExiSfING OWEIIING Tp Tfl[YUBUC SEWER. , CONSTRUCTION LENDING AGENCY ' ► � I he�eby offirm ihat Ihare is a consfr�clion lending age�cy S�GNFDTHIS DAYOF 1� - � tor the performonce of ihe work for which fhis permil is ��Q� OWNERSA T issued(Sac.3097,Civ.C.). npoa¢ss_��S �gD�I��,i�---� ,��- lender's Name lender's Address I certify that I have reod fhis opplicolion ond s�ale thot the above inlormation is conect.I agree fo comply with oll Counry � ordinontes ond Stafe lows reguloting Plumbing ond Sewen, - and hereby outhoriza representorives of this Caunty fo en�er �pon he obove•men�ioned propany(or inspeclian urposes. � �t����� ���/�G Signalure of Pormiltee Do e�� SEf tEVERS[FOt ExRANATORY LANGUA6E __--- _`_-- _._._--� � - ._ . ' . . ,., ^- � Zv �C � , . . . - . ___�"_--- . .' . � � {,�, a. �[� cr} �,^ ���' S , " ' ' � �, . �1 � ? 3{ �N V i� ���-i G � ' _ i �1 '� � �s r �7 � Z" - . • ' . � � � � Oy T .� i�.: �y�i � ,L . . �� l�, p-' 4cr �. . � . 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