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I � WORKERS'COMPENSATION�ECLARATION � - - -. - . � �°#' }�
' I-hereby affirm that I have o ceriificqte nf . �-�Pnt�to self F - � �
insure,or o cerlifiwfe of Workgers'Compensotion Insorance,or ��anen20
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- u Cerfified copy is hereby f�mrshecl. . � � �SEYrGR � �i�ii7�v� W��f�`lA� � ���;
�Certitied copy�s filed wirh the county building inspection i COUNTY OF LOS ANGELES BUILDIkG ANlD SAFETY
�,
depar ment � � - ._ :
oate��Appliconf_�L67 �s���7� y FOR APPLICAPIT TO flLt IN CONNEtT10N DATA >
CER FiCATE OF FXEMPTIpN FROM WORKERS' suamNr, �'�
- COMPENSATION INSURANCE �� nooaEss �j srarion; `�'f�- ,,;�?� oePTH . �-?�.
This section need-noi be com leted if ihe work involved b ihe �J ��`
( p Y � tOCALIiY /J�ANF10tE REfERENCE aO�. , �y'�p . ..
permit is for one hundred dollars($100)or less.) �#'
NEAREST TYPE OF CONNfCTION IFNGTH FROM ��
I certify that in the performance of ihe work for which fhis Ce05557. __ r. � cues et. n4.�.iOP.t. ��J,d' �' ,�
- permit is issued,I shall not employ any person in any manner �' . - � =
"�` N.c No,
so as to become subject to the Workers'Compensation Lows. � ONNER - m.innv.No. ioe Na �'�.�'� ° �'�,
�
. 4 �IL TFUNKff.RMIiNO. ROAOPERN�ITNO. _ �
Date Applimnt 1 nookEsS . � ' "'
AFfIDAVii WAIV:& EASEMENT RECORC.INSiR.NO. DATE ���y�,
NOTIC't TO APPLICANT: If, afier making this Certificate of , ,- ��TY �. TEi rdp. „. �,` _ ' �
Exemption, you should 6emme subject ro 1he Workers' . �wA� _, � ,.r`
Compensafion provisions of ihe Lohor mde,you must forinwiih .- `c aESCeivrioN �oi No. � r t7�' Hwv.oe;T.wioENMG - =�^
tomply wi4h such provisions or this permit sholl be deemed '�"'
Y2VOIC2d. '� BIOCK 1RACi ' � ' STATEENCRQACHMENT- �
� MG.Of 6LGG5. PERf.nl?NO. 9
LICENSEDCONTRACTORSD€CiARATION ' szeo�ior - n�owoNioT � � •
1-hereb a`f�rm ihaf I am 4icensed undar roaisions of Cha ter —�� �
Y A P ����F oF .�.. .�:,�L%�� .,!'O 5�'�
9 tcomrnenang witn Sedian 7(�O)of Urvisiun 3 of ihe 8usi- emio�Ncs_ �- �c�`�pyyz "� ana�es
. ness and Professlons Code,ond my license is in full force and - - —'— — —
@fFBCt. ^y+ y,,�,� ��CON4RACTOR ' � - �. � CONNECTION CHFRGE FEE
LiCenSeNum1ber �fl..3 C 5' LiC.CIasS � - � ADDRE55 ? r r ;��' �` ftEIMBURSEMENTPEE
COYIhOC10� //l�g���y C`3/�ifDpYG'_______� .��CITY h .._�FL.NO. �I4['� "i� ��ISiRiCI NO. CROl1P MAP CROCC$$[0 8Y
�� �a l �p` — s� BKp PG ���"�^""^"`
❑I am exempt uncier Sec of the LA.Co. _ . � tiCENsc No J q J�C�, c ass �y- ¢(j �� „�!j ,,,g�
NO. OFSCRIPTION OF WORK FEE -�� —
Plumbing Code and%or Sec ___of the .— .�iNn�_
PBLSC SEWER CONNECi1NG TO �El DAIE VALIDATION
,{,�
.B.&P.Code for the following reason . - sePi�c raNK,SeeanG=v:i oe j ��
� i�.rs nr��roe QeniuFie.o_ � FiNn� / �_
Ddt2 � HOUSESCWFHCONNF{_iNGTO BY
� .P2NAtE�ISPOSAt SVSTEM � �
�S191YOtUrB_ _ � (S>NNECT ADOlilO'VAL BLDG.OR ►
� OWN[R-BUILDtR DECLARAYION � � `NoaK Tu Ho�SE sEwEp _yi�.-
� OVERiLOV�``EEFA6E P'T,DRAINFIElO.
I hereoy affirm that I am exempt from ihe Coniractor's License ex?v..ces_Pooi,oenveu_n4nnHu�e � �
L�w for fhe foflowing reason(Secton 7037.5,BWsness ond Pro- a�reu;uevnie oa naqNooN iiousE
fessions Code): - . se�,veK oe o.scc'sa:_svsr�M �� �
❑I,as owner of ihe oroperty,or my employees with wages as � _- . . �1 v�5�
fheir sole compensation,will do fhe worx and tfie struclure � . . .
is not iniended or offered for snle�Secfion 7044,8usiness . � - � � �
and Professions Code). OWNER'S P2rmit 5 ,3 r_'� � - �`+ � • • 1 �
❑I,as owner of ihe properfy,am exdusively coniraciing with � AUYNORIZATION TQTAL FEE �� � w t 2��S�.. -
licensed contrcacbrs to wnsiruct the project(Secfion 7044, . �� i HAVE aT rHis onre n coureaci wirH-He Neae�N r�anneo coNrRacroa ro
-BU5ine5S ont�PlofeS5ian5 Code�. � CONNECT iHE AenVE DESCRIBED E%ISi1NG OWE�LING TO iHE PUBLIC SEWER a o n(,'G/��� .
CONSiRUCTION LENDING AGENCY - �- -� , G J V
SIGNE�THIS DAYOP 19, ,� _ rl - . �
I hereby affirm thm ihere is a construction lending agency � ��L�� "��1 - � �
for the performance of ihe work for wh�ch thls permit is - °�^'""-�oR � _
- owN�es nceKi �
issued(Sec 3047,Civ.C1.). J � , . .
Lender's Name�q�[��q.L-?1"fi�L-I . -�J�ij'}_�/�,_,)__ - aooeess ____ . '
- Lender's Address_�.t�j�_S_ ZA �j}('r1.��L�.81�4 �?„;,��, �j��-� � �
I certify ihat I have read this application a d stat thai the� � � .,j
above informaYc is correct.I uyree fo wmply with ali Counfy � - - _ �
ordinoncas and t te laws regulafing Plumbing and Sewers, - � �� -
❑nd he aut r�ze representaiives of this Counfy to enter � �
upon e d property for i soecfion purposes. � - �-:„1
/
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