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1440A
• WORKER$'COMGENSATION DECLARATION I hereby affirm ihat I hove a cxtifica�e of consen�to self }1 .insure,or C certifica�e o/Workers'Compenwlion Insurance,or ��6�efxD , '1 Po14yrNo ��rhlOCompany�S�:`�'�d � � "B°"4`Y."e" qppLICATION� FOR PERM{T ° O ce���f;ed topy is hereby furnished. - SEWER - SEWAGE DISPOSAL �Cerrilied eopy is f�led wirh�he co�nry b�ildinq inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY deb�1 menl oa�� V 26 B6 qpp�icant T. FTeeman FOR APPLICANT TO Flll IN CONNECTION DATA . .CERTIFICATE Of EXEMVTION FROM WORKERS' , �iipi� COMPENSATION INSURANCE nooaeu $ sunon aevTN (Thi:section need not be comp�e�ed if the work involved by Ihe AWNNIXF REiERENGE � UpPEq permit i�!or one hundred dollars(f100)or Iess.� ����T� i R 1 cenify rhot in Ihe performance of ihe wwk for which ihis �RpsSsr. rS �.V8T1 �'r1.821 Tr�����T� ��T"�� . Y. CVRE P.L. MLTOP.L. ' permit is issued,I sholl not employ a�y person in any manner � o�� so as to become subject to�he Workeri Compansotion Laws. o�pR G �o,,,,,.,,�. ,o„�. /d Z� � � � � ��� TRUNKPFRMITN�, ROADiERMITNO. Do�e �Applicanl AODRESS . NO710E�TO APPIICANT: If, oFter moking (�fi5 Ce�tifica�e 0� ��Ty AFFIDAVII WAIVfR EASEMEN/ kECORD.IN51R.NO. OMiE `-emp�ion, you ahould become :ubject ro rhe Workers' r+OV�IIB h���8 8 S nsm�on rov�s�ons of�he lobor code, ou musf for+hwiih �FCµ 12 PQ P Y �ESCRIViION LOTNO. NWY.ORSf.W1pENING .�Sply wi�h such provisions or�his permit aholl be deemed �BYOARd. . &OCR iRACT STATE fNCQOACMMfNT IICENSE�CONTRACTORS DECLARATION "°°°�°�5. c�eMn N°' I�bereby off�rm�hot 1 om licensad under provisiona of Chopter sizeaiot rqwora ior usf oF 9(comme�cing w�ih Sed�on 7000)o/Orvision 3 of the Bosi- �iioiracs a•aces ne»and Professions Code,ond my liten�e ie in full force ond . B/fBCI. �pNiYAROR CONNFRION CH�YGE fEE License N�mber 4Z48�7 ��c•Clau (;,3�, �pp�u KIMBU45EMENT f[[ � Comrocror T. FPe@l�rS B/26/86 - _ DiSiRKTrq. GROUP ,�,.�v WpCESSEDlY o. att ti. ) ec vG � ❑I om e■em t unde�Sec. of the L.A.Co. rArF i�. �a , V P ucer+se r+o. 8S a�ss a Pl�mb��gCodeond/or5ec. � ofthe �- ��R�PTiONOFWORK r�¢ pN� o "o�s�s�'"eR co'+'+ecT'"c To 1'T O onTe YAIIDAT N B.B P.Code for�he following raosan R/BIIC SEWfR y W SFVTIC TANK.SEE��GE PIT OR pNAt �' PITS MW iOR OR�Ir.�F�ID y OOI9 p�JS(5[W[R CONNECTING TO �� T. . ViNATE DIS EM � SigflOtu/e CONNECi AppITIONAI oIDG.G � � � OWNER•BUILDER DECLARATION �K'o Nous�sEw[a OVERFIOW SEFP�GE Poi.ORAINfIFLD ' 1 hereby affirm tha�1 am exempl Srom the Con�roctor's license ExiN.CESfi�'OOt.DRYNRLI.MANHOIE Low for the fallowing reason(Sec�on 7031.5,Buisnexs ond Pro- area,rtennia oa�ewr.�ooni�qusc , . ons CodeJ: 5[wta ae asrosu svsnM '_�,as ownnr nf�h.p.nperry,er my�rt+p!oyees wi!h wcges es ��4�l.�A . their sole compenso�ion,will do the work and the s�ructure �;� • . • � Q is nol inlended or offered for wie($ection 7011,Business and Professions Code). OWNER'$ Permit f ].Q Q . � ,� •2 7,rJ Q . ❑I,as owner of�he property,om excl�sively conrroc�ing wiih AUTHORIZATION TOTAL FEE Ii�p�Sl�COA�fp[Ip/S�O CO�S�fUC}1{l!PlOIB[�(SECIiO�J�d/, �HAV[AT THiS D�TE A�pNRA�f WIiN illF NERFIN N�MEO C0�11RA�lpt 10 �� � ��7.S�(_.� Bus�neu and Rolessions Code). caar+rtT rHc neovt ocuaieEo rxisnHc ow[w.+c ro T�nmic sEwcR. CONSTRUCTION LENDING AGENCY _ . �I , 0 E 2 9—8 6 I hereby affirm thal there is a constructton landing agency . ��DiHiS p_DAYOF 19 ' for �he performa�ce of the work fo� which this permit is °�^'�R� -� pWNERS AGENT ISSVQd(�Q[.3�97.�IV.C.�. AOd1F55 � Landar's Nome � �ender's Addresa . � I cerlify fhot I have reod Ihis opplitation and state that the above information is correci.I agree�o comply wirh all Coun�y ordinances and Srate lows regulating Plumbing and Sewers, � � � . ond hereby au�Morize rep.eseMatives of�his Co�nty io enter , �upon he abave•mentioned property for inapettion purposas. � 7�%1�v-,Z�� ���L�C Signature of Pe�minee Dale SfE REVFtSE iOR EXrLANATOItY IANGUAGE _ f • _ ' D'� G[� � . � qQ ';,� � U�ni. � y . . .� . .. . `h.^V' 6�i/` 'I_^', Z(� t, } p(� T� Q }, 4i'' N �O • .. ' `' d� O O n •;! ? 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