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1451A
-WORKERS'GOMPENSATION DECL4RATION I hereby affirm �hat I hove a certificate of consent ro self [� ins�re,or a ce.tificaie of Wor4ers'Compenwtion Ins�ronce,or 76R611D � �'I � acen�fiedcopyrhereof(Sec.3800�L46C.� � CEBCBfREV.1/B31 APPLICATION�FOR PERMIT " PolicyNo.7b$�ilQCompony gt_ Fund � ❑Ccvlified topy is hereby fu�nished. -. . ' SEWER - SEWAGE DISPOSAL � �Certified copy is fi�ed with�he counry building inspecrion COUNTY OF LOS ANGELES BUILDING AND SAFETY �de� rtment. . � oar�8 2( 8E q�t��o�r T. FY'@6mAri ' FOR APPLICANT TO Flll IN CONNECTION DATA . CERTIFICATE OF EXFMGTION FROM WORKERS' gun�inK, � COMPENSATION INSURANCE ' r.00cess $TATION otnH (This sec�ion need not be tompleted if tha work involved by�he AMNIIpIE REfERENCF uw[a permit is for ons Mvndred dollo.s(SI00)or less.) . ����TY � 1(AR[ST TYVE OF CONNECTION {(�(iN FRpN I certify ihot�n the per/o�monce of the work for which�his crtousr. .�' ].QAII Glen r. cuae P.L M,L.TOP.I. permil is isf�ed,I sholl not employ any person in any monner P_�_�_ O�s r so os io become subjact 10 the Workers'Compe�salion Lows. o�R Anden Grp co.u.v.rao. ipe r+o. 1 Da�e .� . . �APOlicont ' ANDORE55 PO BOX" 2 TRUNKOFRMITNO. RWDPERMITNO. NOTICE�TO APPIICANT:.If,.of�er mo4ing this Certifimle o( ' ��n. 818 6 � AFROAVIT wr.rvea enSen�Ni R[CO4D.INSTQ.NO. DAiE � piion, ,you should become subject to �he Workers' CO�f�II8 TELNO. , � nsation rovisions of the tobor code, ou must fonhwith �EGAI �P� P Y DfSCPIPTION _ lOTNO HWY.pR5T.W10fNING 't..�nply wilh such provisions or fhis permil shall be deemed C flVOkGd.' � ' � ' &OCK TRACT p SinTE En1CWOACHMENT NO.Oi&DGS. PEPMIT NO. ���� �LICENSED CONTRACTORS DECIARATION � saeov ior r�ow ow tpr 1 hereby�off�rm�hot I om litensed unde�provisions o(Chapler usca 9(commeocing w��h Secr�on 7000)of Di�ts�on 1 of the BUSI- BU�IDINGS anec[s ness and Professions Code,ond my 1(cense is in full force ond BffBCf. ' CONTGA�ip4 ' CONNERIpN CN0.YGE f{E license Number�71�887 lic.Closi r.3� - A��55 O RfIMBURSENfNT F(E y v Contractor T. Freeman Da�e 8`�86 �iry o�sraia ra. cao�v M.ov vcocess[n ar O �ti'd OI081.No. / Bic nG . lJ ❑I am ezempt vnder Sec. of the L.A.Co. �,e[N5E rip. � Cu55 � � � ' PlumbingCodeand/or$ec. oflhe ^b� DFSCRiPT10NOf WORK �[E F�NA� � O � MOUSE SEWER CONNERIHG TO �ATE VALIDATION W W&IC SEN4P 1 0� !Z-lG d B.8 P.Code for tha following reoson p}I�T�N[,$[EOAGE IIT p4 �iNai Z rin nr+o�a+oa�i��¢io Dote w�s�s�v+eq cor+Nec'rwc ro ev ' PRIVqfE DISPJS4t SYSTE 5gnorure ca+Ncc��oo�riar���oc.oc � �1 L1 5.1 R OWNER•BUILDER DECLARATION wo�+K 7o wus�sew¢R OJFREtOW SEE A %7.ORAIYiIEID ' i hereby affirm that I am ezempt from the Comroctor's litense EXiN.,CEiSPOOt,DRYWEII,MANIKKE fa. •e • � O Law for the following reason(Secton 7031.5,Buisness and Pro- aiEa,kEa�iR Oa nenr�ooN HOUSF . h � ��On3�O[�l�: SEWER OR UlSlqy.l SYSiFM I,as owner ef the pmp�.�y,o•my...�pl�yees wi!h�va3e5 cs � m •2 7�5 n the�r wle compansotion,will do�he work ond the structure • , •2�.J Q� is not imended or of(ered�or wle(Sec�ton 704d,8usiness and Profess�ons CodeJ. OWNER'S Permif S 1 Q �$2 p��b ❑I,as owner af the properry,am ezclusively conrrocting wilh AUTHORIZATION TOTAL FEE IiC!l150d COf1�lOC10�2�O CO�SflUCf II1B PIO�B[�(SEC�iOfl�W4, �MAV[AT THtS DFTE A CONi4A�T WIiM TNE HEFEiN N4MED CO�'1TFl 10 10 Business ond Professions Code). coar�[t7 iHE neov[DFSCaieEo FaisriNC owtwr.�G to iH[vusuc SEwER. CONSTRUCTION IENDING AGENCY S�GNEUTHiS �� , I hereby offirm that rhere is o construction lending ogenty 0/+YO� t9 for �he performance of �he wak for wh�ch th�s perm�t is �R� � pWNEqS AGENT issued(Sec.3097,Civ.C.). n�oqEss lender's Noma � � lender's Address I carfify thot I have read this opplicotion and state rhat the . � obove infamotion is corrcU.I ogroe to comply with oll Covnty ' ordinontes and Sfote lows reg�loling Plumbing and Sewers, � and hereby a�rhorize.epreeentarives of this County to enrer � . . upon� e above-menlloned p�eperty for inspaction purposes. - �G y i�d"✓(J�lL'�7C� b�/��O� ' Sigrwr�reofPermitlee Dote SEEREVERSEFORE7(►IANATORVIANWAGE 7 ' °�O f _ � . . � . � �,r, � �n op.1; �� �, . . y'vn v f' GN Y �`��� yC^ 'O . • q� � ^ 4 n �),.v � �t1 O� . � }'c� "y O ' � � ' +: !� c? O Y nr �i%` ., .� s����`t�r 7�� Ul� t x " cr� '," r-`. � - � �'�� . , �, ��i;�,L�;:�_ c� ,�� � � f _ . � � .t ' . ' . ;l 7 �F`'T NN n ,` N ' _ . , , . 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