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1776A (10)
' -, WORKERS'COMPENSATION DECLARATION � �I hereby affirm that I have p cerfificate of consent to self � � }) { Insure,or.p ce�lifimte of'oVorkers'CompensotiOn InsuranCe,o� 'SAod�D U ; �'�og�,=Y h�eo���:PQ�`ab�-.�,�__ `:e°e'REv�,�'� pppLlGATION FOR PERMIT � (-!c��,�r�ed�oPY is hereby fumished. SElR�ER - ��`hr�iG€ JESi�C3�AL � ❑Ce�tified copy is filed w�th the county buiiding inspect�on COUNTY Of LOS ANGELES BUILDING AND SAFETY depor enL � Dare pplican+__� FOR APPLICAN7 TO FiLI IN CONNECiION�ATA CERTI CATE OF EXEMPTION FROM WORKERS' ewioiNc �/ i COMPENSAT�ON INSURANCE no�aFss pt srnnow oevrH g (This section need noi be compleied.if the ork involved by rhe uvv¢a ' � . � �«A��r� M4NHOLERfFERENCE �QWER �, permit is for one hundred doliars($100)or less.) I certify thot in the performance of 7he work for which this NE°'REST j cr. �YPEOFCONNECT�ON t�N�iHfaovn �RO55 ST. ��' Y. CURB P.L M.t.TO P.l. permit is issued,i shall nof employ any person in any manner € ;o as ro become woject 7o fhe Vvbrkers`Compensation Laws. pwNee CO.IMP.NQ J08 NO. { If MAIL �j Date, Rppiimnt ADORE55 -� TRVNKPERMITNO. ROAOPERMITNO. AFFIDAVI7 WA!YER E0.5EMENi RECOYD.INSTR.NO. DATE - NOiiCE TO APPLiCAM: If, after making ihis Certifimte ot arr ret.No. f rj�� ' �myption, .you should.become sobject to ihe .Workers' if�A� ._ 3?pe�sotion pro•+tsions of the La6or code,you must forthwith DfSCRIPilOu lOi NO. � � ' HWY.OR ST.WIDENING c�mply with such provisions or fhis permit shnll be deemed - � �evOkBd. . Btp[K iRACi �. STqiEENCkO9CHMENT LICENSED CONTRACTORS DECLARA710N n�o.°��a�s . PERraiT Np. I he�eby affirm ihal I am licensed under pravisions of Chapter 5¢eor io� Nowov tor . 9 commencin wiih Secfion 7000 of Division 3 of fhe Busi- ` US[oF ( S � BUILDINGS 1�'i CHARGES ness and Professions Code,nnd my ficense is in fufi force and �-- � � P�eC1� '$ a�a(��- CUNiRACtOR COYNECTION CHAHGF fEE . � License Num6er �1�✓[3(,J �j�_��OSS q11pRES5 REIMBURSEMENT FEE ' � COM�a[tOf�� tl�e � $,� DISTRICi NO. GRWP� MAP GROCESSEO BY � ' CIN ` iEL.NO. P(J' `� � � � . ❑I am exempt unde�Sac. of the L.A.Co. iicENs�n�o. � uC. S� �� �, eK vc � ��� � f cLA55 jJ � N�. �ESCRIPTION OF WORK rfE �- � Plumbing Code ond/ar Sec. of rhe F�Na� � . V �Nouse s�wea coNNecnN�to 1 oarE=�, ��-. VqLIDATBON � B.&P.Code for iha following reason PueuC SEwER �. - � � . SEPTIC TANK,SEEPAGE PIT O£ P1T5 AN�/OR 0'�AINiIElO FINAL - � DaYe HOUSE SEWER CONNECiING TO BY �.,i +S ._... . � PRIVATE O�S�OSAl5V5TEM � �T '� � $1911afu�E COhNECi ADOITIONAL 9:DG.OR ► - � 01M1'Nc'R-6N1DER DECLARATION woaK to r+0use sewea . OVERF,OW SEEGAGE VIT,ORAMFIEID �; I here6y affirm ihot I om exempt from the Cooirattor's License ExrN.,Cesscoot,DRrWE!t.Haa.yae - � Law for the following reoson(Jeclon 7031.5,Bui;ness and Pro- Auea,aeatiie pa nflaNOON HOUse . - ' -aons Code): sewea oa oiseosni svsrer�n _ .. - _.:�1,os owner of!he property,or my employees wifh wages as fheir sole compensation,will do ihe work and the siruciure - .j is not intended or offered for sale(Section 7044,$osiness and Professions Code). OM/1�ER'$ P6fmit S ❑I,as owner of the proper�y,am ezd�sively contracting with AUTHORIZA710N T�TAL FEE � �� licensed CO�fIOC!O�5 10 consirucl the project(Section 7�44� i HAVE AT THIS DATE-A CONTRALT WRH iNE HEREIN NAMFD CONiRACiOR t0 "� � '7 �'��� � Business and Professions Code�. � WNNEC7 iNE ABOVE DESCRIBED EXIS7ING OWEiLING TO iHE PUBLIC SEWER. ' - CONSTRUQION IENOWG AGENCY `��2,`e W s m � � .. ��. I hereby aff'nm ihat 1hCre is a construclion lending agency SIGNEDTHIS DAYOi 79_ , � � :�- far ihe performance of the work for which ihis permir rs �owNeu oe � ��, ) � �� �.�j(`,I OWNERS AGENT - issued(Sec 3097,Civ.C). / o r. ` `�j O_� ' �nooRess e G r. � l'�e�nder's Name r�Y�7 F(( ��� a � . . Yeri'der�Addres����• �3 G 2,�g�"`��1 I certify iha� I hove read th opplimtio an state thar the . above information is correct.I ogree to w piy wifh all Covnty ordinances and State low reguloting Plumbing and Sewers, �_ and hereby authorize re r seniatives of this County to enler up� obove-menfion property for inspettion purposes. . �' ignoture f Permfitae� Dafe � � SE"c R'e'v��Csi�OR EX�iANA70RY IANGUAGE . �� ,;.: ,.d..„ ,; . . �,.DQ�N ..� ��:M� Z � . ++ �CO �..� ; ._. . . ' .. { � F zp�j�� � obl�n � t� ! 4 � ,..� .. � . i '. S v� Z vv� 07 py� U, '$�� f . 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