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0981A
WORKERS'COMPENSAiION DECIARATION .I hereby affirm thor I have a ca�tifico�e of co�sent �o self • . . . � ins�re,or o certificaie of Workeri Compenw�ion Insuronce,or 16A612D ' � �� a cenified copy�heroof(See.3800,lob,C.) �E�e�aE°.,,83, APPUCATION FOR PERMIT -�. poljcy No1 . , . Compc y �..C.�,r. ::� :,;"` Fy� -�!. 1 � r SEWEFt - SEWAGE DISPOSAL � f[J Cer���ed�copy is hereby fu�nisfstd. ❑Cer�iiied copy is filed wi�h�he coumy bu�ld�ng inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY ' deportmem. ,� �oro!r''"•.=!�+-��'���Applitanl r�' ` =-.�''1J�'`( FOR APPUCANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' eunww ..., l_�.. � sr�norr am+ . COMPENSATION INSURANCE noocess �ri� � 1 5 �.'�I.7 � �ibit seUion need not be tompte�ed if the work involved by the '� - � -•,��..�-� - � iwwHptF qErEkEEnKE . uwER permi�ic for one hundred dollars(SI00)or lesa.) �«°'°T� `"�. i�" '_ ' " ."'�r���'"���� a I ceriify ihat in rhe performance of�be work(or which�his �rto�sssr. %':�'^"�%e:= i :.rl��`�'`�J� '.r�iJ•=.•'.L7 rraeorco�r+tcrw'+ �r�tHraa�n r-.:,-- Y. NR! v L M.L To v.L . permit is issued.I sholl not employ any person in ony monner f P�� � � so os to become subject to the Workers'Compensalion Laws. p„f�R �� 1��- , ��,,�,!;�.��C � ca unv.Np, ipe r�w. M411 . .. �..�:G.;' q!�,IP 74UNK PERhVT NO. VOAD OEQM17 Np. Da�e Applicant ADDRE55 fh-�� •%::�Y�' .� ._ � � t � � AfFi0AVi1 WniV4R FASFAAENI YFCORD.INSiR.NO. W/E NOTICE TO APPLICANT: If, aftai making ihis Cerlificate ot nT�j J;;., :..1;;•r',,�r�r�p, �/�l. �;-j��_�:'"' Exempt�on, you should becoma sub�ect to the Workers' LEGPA Compensation prov�sions of the Lobor code,you must for�hwith o[scaiarioy torrao. `JC% �wy.ptST.�no�wr�c comply wi�h such provisions or this permi�shall be deemed �-n- revo4ed. aioCe TCA[T ���!�.. STAfF FNCROAGMMENi LICENSED CONTRACTORS DECLARATION wo.a e�ocs. � ffv'"T"'�. q size ov ior ruow ow ior �� I hereby oNirm�hot 1 am licensed under provisions of Chop�er o(commencing with Section 7000)of Division 3 of the Busi- euiion+os ih`�.S�r��I��LL' d�x,�s � ness ond Professions Code;ond my license is in full force and . � effect. . '� CONIYAROR lJ i�•r � Y?•�(I✓��r\j t.('J�� CONNECTKKJ CN�4GE FEF� 6 r - License Number'��>`�^�•�I Lic.Class �DDRF55 �i`�% �fJ��!/�L/J 7 '�'�G' ff1�UP5ENFNT i(E V . Contractoi t1 �r/?'�."'.tlr:�Da�e ��.:.��- `%� aTr ',A�f.�.IJ.-i' rei.wo. f � 7{:�� D�SI41C1 NO. GQdJV r+,nr � vaoctss[o er W • � 7.: � :?- . :�� � � � ❑1 am eiempl under$ec. � of�he LA.Co. ST�Ng rp. /J'%'� '��l nnss .-<• ,/•; �✓"r' �' ' NO. DESCRIPfION OF VlORK iEE Plum6ingCodeand/or5et. ofthe FNAI VALI At1oN � a inus�s�v.�R cour�cnwc ro o•re � B.8 P.Code for the following reason ;�'. w&K s�v.�° SEvnC TANK.SEEv�(,E M7 OR � FiiS AND�OW OkA�NF1E�D ���� ' y DC1E 1qU5E gWER CONrICTING TO �� W � ' � NIIYA i YSiEM . • Signoture co�+r+[c7 aooiriorn�t eioc.ok � t. OWNER-BUItDER DECIARATION �K to'+ous[56wta OVERFtOW SEEG�GF�i.DV�iNiIEID ' I heroby aHirm tbat I am e.emp�from the Controc�or's license EXiN.,CESSR')pL,ORYWE/l,hNNROIE - Law for ehe following reoson(Sec�on 7031.5,Buisness ond Pro- �uhrt,rsennia oa�e�r+ooN rqus[ fesstons Code): sew[R oa wsrosu svsreM . 1.r.^,.1,i. _,',�. � .Q I,as ownei of tbe Propertv,or my amp�oyaes with wages as � ..., r..:.c �5�.:� S-�:! - .. �beir sole compenao�ion,witl do the wwk and�he strvcture �.'�"'�o'�"�i�:l�. is no1 intended or offered for wle(Seclion 7044,Business •,a y��� � and Professions Code). OWNER'S Permil f ,�j,��,j;�;�:�1j[j ' ❑I,os owner of�he properry,om exdusively controcting wirA AUTHORIZATION TOTAL FEE ;�. . :- '..'%,i';;'r,;(�(1�', I li[ensed tO��roclors to conshvcf the projecf(Sec�ion�04d, �HAYE AT THIS DATE A CON74AC7 WITH fME HERIN NANED COI�ITQACTqtriO � � ' � Business ond Professions Code). [a+r�[a rN¢neovc ocxciaeo exisrnae owEiur�c ro r�+c ruazK sewtR. 1;.[�4��':i��; � . CONSTRUCTION LENDING AGENCY � �;.r �f�`f.- f_. , ' 1 hereby a/firm ihal Ihere is a consirotl(on lending agency SIGNFD THIS •' DAYOF^� - 19.'��` - , for Ihe performance of ihe work for whith �his permil is ��R� e •�i,..y"}•_C 1•,i,��.�-/''��� � OH'NFR5.4GfN1� ���� itsued�Se[.3007,Civ.C.). � � � , � , ' AODRE55 %�'=J �!, i'./�.i.�/..� I'}-�!�';�/•.f;jL �� +� � . Lender's Name tender's Addresa � ' � I cenify thot�have reod this applicotion ond sto�e�hat�he . • . a6ove informalion is correci.I ogree fo comply with oll Covnty , . ordinances and S�ota lows raguloting Vlumbing ond Sewen, � , � and hereby autfwrize representatives of this County to enter ' ' , � � � 'vpo�ii�bove-meMioned propeny for inspattion orposes. ' w � ` `�„.. J� i .r� � .. /�/ /i r i i�l 1 r:..'� !-'-'� :�.� . '� Signatu o}PermiBee /,/ Dofe.: SLE REVERSE FOR!%�IANATORY IANGUAGE � f.. . �y�, l_=-l..r ' '.�;.__ ._�ly.. 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