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0979A
WORKERS'COMPENSATION DECIARATION � � � I hereby offirm �hat 1 hove a ceriificare of crnsenl to self ' � insure,or a tertifitate o(Workeri Compenwtion Insuronce,or J6nda]D - ' o cerfified copy Ihereof(Sec.380D,La6 C.) CEBOB�REV.1/Bll APPLICATION FOR PERMIT - .� Policy No. Compony ^'(��r'!`��'�'/� . � ❑Ce iified c Py ii hero6y fumiiK�a. SEWER - SEWAGE DISPOSAL � ; � ❑Ce�rffted copy is iiled w�rh rhe counry bv�ld�ng inspecron COUNTY OF�OS ANGELES BUILDING AND SAFETY deporlmen�.r r y �oro �-"�=�`�fSaPPn�o�� r=.�`-�• '���t�'��--� FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' - � eui�� ���� �f.�/L „1���?,,� st�riorr o[►rH ' COMPENSATION INSURANCE (This section need not be completed if the work involved by ihe ,�,f y— '����, �! //�, ,qpNHplE REfERENCF u°°fR permil is io'r one hundred dollors(5100)or less.� LOU'4TY "j�'�,�'T•� �...� , C,i _ J.:��1:• � � NEAREST " TYPE OF CONNEC710N {[NGTH fROM �certily Ihot fn ihe performonce of.�he work for which this cRossst , -��%:-- ti� %;.:7 r.�,I�:%��r�J=".L�- v. Curte PL M4TOi.L. � permil is issued,I sholl not employ ony person in ony monner � , p�� � so as�o became subject to fhe Workers'Compensation lows. � p�y�R �; ,//. .r 1���,4?�r to.iMv,rao. �oe ra. � Da�e Applimnt A�oo�cess I�'/)I r+^��'� ''r-�.'�. �n �RUNKIFRMITNp. ROADOERMITN�. ' ._~ .:~ .. AFHDAVII W�IVER EPSEMEM RECORD.IN514.NO. W.TE NOTICE TO APPLICANT: If, ofter making Ihis Cerlificate of nTy f l,r� rE�,,.,o.. tt:y�%�'3�%_,:i� Ezemprion, yoo should become subject to the Workers' tewi Compenwtion provisions of the Lobor mde,you mus�(or�hwiih orxaivriora lOTNO. �J- NWV.ORST.WI�fNIlJG � comply wi�h such provis�ons or�h�s permit sholl be deamed BLOCK Tana L,��� /���� sr•r[[Ncco�cNr+,�Nr revoked. LICENSED CONiRACTORS DECLARATION r�o.or xocs / ocw.rt r�o. SIZE OF lOT NOW ON LOT � I hereby ofiirm Ihal I am licensed under provisions of Chapter �� 9(tommenting wifh Section 7000)of Division 3 of the Busi- e�itoit�GS :'�f�/r��'�J"�L- ww�[5 •ness and Prafessions Code,ond my license is in full forte ond 4 � CONNECf10N CNARGE FEE ._� effec�. � /�lt cdarennoc ; +:r�xJ�.�/�.eJ�'li'� _t=Ni /.i�,- • y ticense NumberL'.�`�-���� t�a Class/ rr ADDRf55 �I!-:. ,J ����/fJ �'f'' =°�fi ��U9YMENT F[f V � � Y'��_I�"'::�7 � I ••,• + )/..�",'•:,� DISi41CT NO. GQOUP MnV PROCESSED Bv ConKaClor � : "'G/��-:/ DOte PTv t..,.l':.f/��l.fl TfL.NO. �� / `/�.r ^`C.% BK �f. j ❑I am exempt onder Sec. of ihe L.A.Co. ueeNse wo. �;��!�=�I` ' tiAss �� % ' u' Plumbinq Code and/or Set. of the �� DESCRIPTIqJ OF WORK r�e ry�i � � '7 �w����Rcor,r.�rnr+cio w*E VALIDATION a � B.8 P.Code for ihe following reoson oc � $FViIC TANK,SEEVpGE plT OR Dote PITS AND/OR DRAINFIElO e Al � ` ��DWFR CdJNFCTM f0 � SignO�UfG . CONNFCT AD0111ONAl&DG.OR � ' W - OWNER-BUIIDER DECLARATION � `"°RK to"°�s�s�"'E° ~ OVEflFLOW SEEVAGE PIT.DRAINfIELD ' . t hereby oHirm thm I om ezempt from the Conrractor's License EziN_,CESSVJOL.DNYwEII.MAN1qlE � law for the following reason(SeUon 7031.5�BUiSnlSS Ond PIO• Al7EN,REGAIR OR ABAN�OIJ MOUSE �. fessions Code). s�v.�e oR oisPosw�SrshM •^:�1.�; . . ❑I,as owner of 1he prope�ty,or my employees witb woqes as - ` � '�' , �,'`�' ����� �heir sole compenwtion,will do the work and�he strottvro ,:'�a��:'s��✓fr j�� � ., is not iniended or offered ior wle(Section 701a,Bustness � ''; '� , and Profess�ons Code�. OWNER'S � � ❑I,as owner.of the poperty,om e:dusively mMrocting wi�h AUTHORIZATION TOTAL FEE f � ` ������j������u. IIClnSld COl111OC�O�S f0 COnStNC1 7I1B P�OjB[I(SBCIiO�7D44, I HAVE AT THIS DATE A CdJTRACT WiiM TME MEREIN NwMEp Cp��A�TpR TO ���.i��:�•�,'7+.L�-� BUSIfIM4 011d PfOf25510115 COdB�. CONNECT TME ABOVE DESCRIBED E%ISTING DWEILING TO TMF vUBIIC SF�MER. �,. „�,y�.,� CONSTRUCTION IENDING AGENCY •J,/ •' � • �`�F��•'��t'�•` 1 hereby affirm 1ho1 Ihere is a tonslruction lendinq aqen[y SIGNED7H15 �r DAVpi �!'���r f_ ► for rhe rformance of rhe work for which this rmit is �""'EROR 'R•���.�;•i'�'-;�[ •';�'•.!. �� � ^ P� PB OM/NERS pGENI ^ .• /'.: • 1-� iSSV�(SBC.�7�CIV.C.�. ADDRE55 /+..�%: l�'%.`-/�%.:..i�. I/f�i�/JC..•.i landei s Name � � lender's Addreu ' I carrify Ihal I have reod rhis application and stote�hol the � ' cbove informalion is corract.1 agrae�o tomply wi�h all Counry ' _ � ordinontes and Sto1e lows reguloting Plumbing ond Sewers, and hereby outhorize representofives of Ihis Counfy fo enler � � - � upon the obove-mentioned pruperty 1or inspec�ion.purposes. - � � ' (. ' �x,-,= 1�_/.�. �...-� ,-�.... � • �/r`;rn .,fi/" ; ,..r�:+' .r�.`�;-� � I Signafur of ermillee - r / Dal��� . 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