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� WORKERS'COMPENSATION DECIARATION � I hereby offirm thot I hove a certifico�e of consent to sel( � {� insure,or a ceriifico�e of Workers'Compensation Insurance,or. ��'�D ' 'II d cerufied co thereof(Sec.3800,l06 C.) �E BOB IREV.1/831 �� Po���Y No.��Compomst. �a APPLICATIQN FOR PERMIT ❑c,:,;f;,d�oPY;,h„ebY�,,,,,;,h,d. _ SEWER - SEWAGE DISPOSAL g]Cenified copy is Rled wi�h�he couny bviiding impection COUNTY OF LOS ANGELES BUILOING AND SAFETY depo�tmen�. � � � oaie�SApplican� T� j�E+n,mBT� ' fOR APPLICANT TO FILL IN CONNECTION DATA CERTIfICATE OF EXEMVTION fROM WORKERS' . �iiq� . �� . :COMVENSATION INSURANCE � nooa�ss siAn°N o�°iN (This aeclion need nol be completed i(ihe wwk involved by Ihe i�inY MAPINpIE REfERENCE uc�vea permi�is for one h�ndred dollors(f100)or lass.) ° r[na[sr Trvt o�tonr�tr�ow �[rwrM raaM I�certi{y�thol in�he performance of the work for which�his cposs sr. r. cuxy pA, M.6�O P.l. permil ia issued,I shall not employ ony person in ony manner P�� c so as lo become subjecf to the Worken'Compenwtion laws. owr+[a Anden G C�,iMv.r+o. �oe No. [�yp ��� iRUNKifRM1TN0. ROi10ifRMITNp, Do�e � App�icant ^�u Y BOX�� Z AFfIWVII W/IVER f�SEMENT R[CO4p.INSiR.Np. DAiE NOSICE TO AVPLICANT: ff, after making �his Ceriificoie of cirv r¢i.r�o. • � ption, you should 6ecome zubjact fo fhe Workers' if�i � �pensaiion provisions o/the lobor tode,yoo mvst fwthwith oescaivnprJ toTrvo. Hwy.pt 5T.ywo[Nir�e . �„mpiy w��h s�ch provisions or th�s pe�m��sholl be deemed �/C fCVOkCA. � '� . . &OCK ' iNAR (Vl SIAIEENCRp��HMENi LICENSED CONTRACTORS DECtARATION � rao.a e�ocs �'ERMIT NO. SIZE Of tOi NOW IXJ LOi I hereby'offirm�ho1 I om licensed under pravisions of Chapler 9(commencing wi�h Section 7000)of Division 3 of ihe Busi- eloin�s Sin • R6H• a�s ness and Prolesaions Code,and my licanse is in full force ond efflCi. CONfRA[fOR m �n t CONNECTION�HARGE i{E litenseNumber 474887 �;�.c,a,s.� C3�� „�u g 2 ee hw O ���1¢Sf/.�FMFEE ,�, �o��.o��o; T. Freeman�,e e/26/86 �„Y glta Zoma. ,E�.� 7i4/9sa4429 �"`""'"° `�'° BK ,""° � °�"��B' � ❑I am exempt vnde�Sac. of�ha l.A.Co. uCENs�{.ip. f�7l1.887 �,� C34 �d �o �+0. �f$CRIFfIptJOFWORK ifE �.. Plumbing Code and/or Sec. of the FINAI VALIDA ION uVi 1qV5E$EWEi CONNFCi1NG TO � DATE b B.8 P.Code for�he following reoson ���T�N��SfFP�I[�T pl av � 'O Z PITS ANp/O4�iAiNi1ELD flNAI Date ,qusE s�R cor�.xcn.�c ro er xnv� i sr Si9110Wre � � �ONfJFCfADDIT10NAtlLDG.OR � OWNER-BUILDER DKLARATION �To"°�s�scwn` OVFRfIOW iAGE Ri,pR111NFIElO I hareby offirm�bm I om exemp�from rhe Controctor's License Ex�N.�($SPpp�,pRWhIL AUNMpIE law for the following reoson(Secton 7031.5,Buisneu and Pro- .utEc,atvuR ox�ruoa.��aust � ' �ons Code�: s�wta oa olwosu srsnM :� 4 Q H A ,_,'I,oa owner of 1he property,or my employees with wages as ��• • • • � O their sole compenwiion,witl do�he work and the shuc�ure is nof Infended or oRerod(or wle(Section 7044,Business . � e s z 7.Jr O ond Profesaions Code). OWNER'S P��m�t = �j'y` ❑I,as owner of the property,om excl�sively controding wirh AUTHORIZATION TOTAL FEE e o .�7 j C� littnsed toMrottors to constrvct fhe projecl(SeUion 704�� 1 HAVE Af THI$DAT[A[pJTR�I WITH TVIp MEYE�N NM1ED CONiR�(TO4 ip �t Business ond Professions Code). corJr�R rHe neov[asca�e[o txisnr+c oxrewr+e r0 rH[Puxic 5[wta. 0 q 2 4�8 6 CONSTRUCTION IENDING AGENCY �j , I hereby affirm tlrot there is a conshuclion IBnding ogenty ���m15 DAYOF � 19�+ fw tha periormonte of �he wo�k for whith fhis permil is °N'r�eRoa OWNFMSA T iswed(Set.3097,CiV.C.J. ADORESS � � � lender's Name lender's Address I cer�ify Ihat I have reod�his opplicorion ond s�ote rhat�he � above informolion is correcf.I ogree to comply wi�h all Couny ordinances and Srote laws regulaiing Plumbirg and Sewers, . ond hereby authorize representotives of this County�o anter �po the above•menfioned property for tnspection purposes. � � •, �> �',11�.1sv �'�L���i Signalure of Perm�nee Oate � SEE R[VERSf FO�E7I►UIHATORY LANGUAGE � ' ' � � rr `� 7 . . _ ' . . , - :.� '. .`".�, <.. ��� 1 � . 1 °T ^��� o', R �% T 7�� C� � i �1 E, . ; ° �.� � L';. c•� D . i � 1 � Z;, �,� rrt �r � . 1 : I , r� fl D 'U D� V � . . � � 1 �1'_: �'� T o �.� � '1 � '1 { . 1 . J ��C 1:� �. A.�� O . 1• '� 1 . . , m(1 ).:. < �'' ' � ' ' ^ �S L''c'„ ,� 'r'_t r� ➢ � ' ' . � . � , , ' z'• ,�.v '�x ��L � N . . . : ' �_ • i 1 . •' r� � � , ^ �,---�- ; ; :. , �� .-•.�': , .. ? ""�`� c� . N '� . . � � : i � � r��+ i 1 � � � . � . 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