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1435A (8)
WORKERS'COMPENSATION DECLARATION � I he�eby offi�m �hat I hove a certi/icate of consent to self . Q insure,or a cenificote of Wor4en'Compensa�ion Insurance,or �d"°'7o �II aceriifiedc����fp-r5a�.�,��:.,�d . �Eeo9�aEY.,,e�, � APPLICATION FOR PERMIT " � � Policy No. com��Y . SEWER - SEWAGE DISPOSAL � �Cer��fied copy�s he.e6y f�rnisbed.� Cerfified cqopy is filed with ihe co�nty building inepection � COUNTY OF LOS ANGELES BUILDING AND SAFETY � Doia�2�/86 Applttanl T• F='eBID3ri FOR APPLICANT TO FILL IN CONNECTION DATA CERTIfICATE OF EXEMPTION FROM WORKERS' BV1LD1� 850 Feathe wood srniwrr ocarH COMPENSATION INSURANCE • �no4css (This secuon need nor be compieted if the work invoived by�he �w�aE xcc[ffutt �° pefmit is for one hundred dollon(5100)or less.) � . 1OG0ry - R I ce�ti thor.in the rlormonce of�he work for which this ���ST irt[pc cONn[pqN ��iH�qµ fy Pe CNOSS Si. S 1PC�Il Y. NR! P.L. M.L T0 7.1. pe�mit is issued,I sholl not employ any penon in any manner ' . P�� so as to become subjed 10 the Workers'Compenwtion Laws. p�Q G` Co.uu.No. �oe rw. � . ^^�k iQ�rHc c[rtMit rq. kWn vte�xi N0. pote � APPlicont � A0°REu NOTICE TO APMICANT: If, aher making Ihis Cerlifimte oI �iTY AFiIDAVII WAIV2R EASENIENf RECORD.iNSTR.Np. W.TE � ��nption, yoo should bacome s�bjeU lo the Workers' COV�A8 tEi.r+o. BZB 6 � , bensarion rovisions of rhe lobor code, oa most fonhwith oescRivrioru ioTr+o. P Y HWV,pR ST.WIOENING C...��ply wifh such provisions or Ihis permit shall be deemed �GVOItGf�. ' ' BLOCK 1f1ACT SfATE ENCR04CHMEN� LICENSED CONTRACTORS DECLARATION Np,pF&DGS. ffRMIT NO. 52E OF tOT NOW pN LOi �6ereby afFi�m rhm I om licensed under provisiona of Chop�er � . 9(commancing with Section 7(q0)of Divialon 3 0(the B�si• eu�ii,�r.�s Sin . Ree• anacEs nesa and Profeesions Code,and my license is in fuil io�ce and BffBCf. �ONTRACiDR CONNFCiIONCNARGEFFE . � • � Licenae Number d7�rRR7 Llc Clau � f��4, ���u REiM&1eSEMFNT FFf � y �O�IrO[bfl• Freeman pO1Q 8/26/86 CITY I.NO. DRi4iCIN0. GQOVP � MAP � MOCESSEDBY V ❑1 om exAmpt�nder Sec. of the L.A.Co. iiCcr�+st uo. a8� an55 (v � � � �PlombingCodeand/orSec. oflhe �� OEKRiPf1pNOFWORK r�c FINAL V �ous�s�wERcor+r.�cr�r+cTo 1 Q o"TE `Z—LZ^ VAIID TION � . B.8 P.Code for�hs fotlowinq reoson ' °UB°��'"�° VTK �NR,SEEiA %7 dl N ' PIfS ANp/OQ CRAINFIElO NNAL Z Dare ���v.4a caa�crwc To er .- . va�vn oisrosu rsr�m Signo�ure . cONw[c��ooir�orui a�oc.oa � OWNER-BUIIDER DECIARATION �ro Novs�s[wcR I beraby of{irm Ihat I om exempt from the CoNratbr's Ucense E%7NF�CE55NOt DIi IYWERAhWN�MOIE low 1or rhe following rcoson(Sec�on 7031.5�BViSneu Of1d Vf0- M1E0.REP�IR pt A6AN�pIJ MOpSE ,.�OnS COdEJ: SFM'ER OR DISnOY.L SYSTEM C 1 U 3 5 A 4 0�owner of�he property,er my empinye�s wirh wages oe . �� � � � , � their sole compensolian,w�tl do the work and ihe en�ct�re is no1 inlended or offered fo�w�e(Sedion 70e4,B�siness and Professions Code). OWNER'S Permit S I •a 2�.5� ❑I,os owner o(fhe property,am ezclusi�ely contratting with AUTHORIZATION TOTAL FEE litensed toNmttora to conshutt the p�ojecl(Setlion 7041� �HAVE AT MI$OATE A CONiQ��T WITN iN[H[pflN NI.MED CONI AC pR f0 � ' °2�•��� Bus�ness and Professions Code). cor.�Necr THt aeovt oexaie¢o exisnr+�owtuwe to r�ni�ic s�we4. 0�.2 9�a 6 CONSTRUCTION IENDING AGENCY �j/ I hereby affirm thol lhere is a construc�ion lending agency SIGNEDTHIS�DAYOF � 19 (or fhe performonce of the work for which ihis permi� is �"kq� OWNER$AGFNT �:���a(sea 309�,c�,,.c.�. . ,,pp�u 822 e.chwood Dr_. A�ta 7.0 Lender's Noma lender•s Address I certify fhat 1 have read Ihis applicalion and slale that�he � obove iniormation is cwrecL I agree lo comply with oll County . ordinantes and Slate lows regulating Plumbing ond Sewers, � ond hareby a�lhwize represenlotives of Ihis Counfy lo enler � �pon 1h above•menlioned prOperfy for inspection p�r ses. - � �,��.. s�°t�: . 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