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1779A (10)
. �� • WORKERS'COMPENSATION DECLARATION - i hereby�affirm tnor i nave a certiricate oi coosent to seli - , 5i insure,or a certificote of Wnrkers'.Compensation fnsumnce,or ?eneazo �� � ° ��; �he�e�L�..(y�-:�,t°e,���`., � `E s°�`RE�,,a" APPLICATION �OR PERMIT Pa i�o.�Co4npony 4�s� . ❑ce«�r�aa�oPv�s he.ebv s�,n�shed. SEWER - SEWF►G� DISPOSAL ' Q CerriYed copy is filed wvth tfie coonry bulldi�g inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY' departmen. _ - Date_�r� App�icani� � FOR APPLICANT TQ PILL!N CANNECTIAN DATA ,_CERTIFICATE OF EXEMPTION PROM.WORKER$' nui�owc /J i 57nnON ��TN COMPENSATION INSURANCE noozess ����� . (This sectron need not be comple�ed if ihe work.invoived by the t�.aNHoie aeFeeeNce uPr`R , permit is for one hundred dollars($100)or iess.) �aAurr _ iowee NEAREST TVPE OF CONNECiION IENGiH FROM _ I cerGfy�hat in �he performance of�he work for which this caoss sr. r. cuua r.t. M.i.To P.i. � permit is issued,I shall not employ any person in any manner - - � so�as ro bemme sub ect m the Workers'Com ensafion Laws. v.c.No. , � P OWNER CO.IMP.NO- JOB NO. . ��� � TRVNK PERMIT NO. ROA�PEttMlt NO. . Da1C APPIiCor11 ADDRE55 N�T�[E TO APPLfCANT: If,�aker makin ihiS Certificate Of_ AFFIDAVIi WAIVER EASEMENi RECORD.INSTR.NO. DAiE � . J CIiY TEI.NO. �"J� .. � tmption, you should become subject to ihe Workers' �ecnt y, � ;ipensation provisions.of the tabor code,.you must torihwith oeSckiPiioN to�No. Y�' Hwr.oe sr.wiDENwG � comply with such provisions or ihis permit shall be deemed revoked. - etorK TRACT STAiEENCRO9CHMENI ' � LICENSED CONTRACTORS DECLARATION - r+o.oF amcs. FERMii No. : 51]F OF l01 NOW ON Lnl I hereby affirm tha9 I am ticensed under provisions of Chaple� cse or 9 (commencing wiih Section 7000)of Division 3 04 ihe BUSi- eUILDiNGS CHneGes - ness and Professions Code,and my license is�in f�ll force and effeCf. `� J y., �{l� CONTRACtOR � CONNECTION CHARGE fEE LiC2n5e NUmb r J7l�V Li[.CIO55_'�✓ AnD4E55 � . � 'REIMBURSEMENi FEE Q�. Cun1YIXtOf Oie y t' � f DISIRICi NO. GROUP MAP PRpCESSED BY � � CIiY 1EL,NO, �� �f ❑I am exem t under Sec. of ihe L A.Co. s'^'e g uc w � BK ve � . P LICENS[NU. . I� .Z�. C1A55 �� � y�,(9 � N0. DfSCRIPTION OF WORK FEE t"' � Plumbing Code andior Sec. of the FiNni t7 t HOlISE SEWER CONNECTING TO DATE..� , ,ye. VA�ODATION � 8.&P.Code for ihe following reason /•PUBGC SEWER 7 � +, � ` "'' -� � $EPTI�T0.NK,�EPAGE o1T OR filvA PITS AND/OR�kAINFIEtD aY � �. ].. � Date HOUSE SfWER CONNECTING TO ��,,,. GRiVATE 61SPOSAt SYSTEM ���� SIC]f1O1UfC - COM1NECi AOa1tIDNAL BtOG.OR ► y OWNER-BUILDER DECLARATION woRK ro Nouse sewea O4ERFIOW SEEPAGE Pli,�RA�NFIEID I hergby offirm fhat I�m ezempt from the ContraUor's ticense exTn�..ce55vooL oerweu,nnr.NHote - Law for the following rea50n�Setton 7031.5,BUISneSs and Pro- ALTER,REFAIR pR ABANDON HOUSE ' ':9n5 COd@`: SEWER OR DISPOSAL SYSTEM �"I,as owner o#the property,or my employees wiih wages as fheir sole compensation,will do the work ond the structure is not intended or offered far sale(Section 70-04,Business 4'_. 7 7.�� and Professions Code). OWNER�S Pertltit S +D � ❑I,as owner of the property,am exdusively contracting with AUTHOR►ZATION TOTAL PEE �. �j'�,,y "� �' � `� � U licensed mnfractors to construct ihe project(Section 704d, i Hnve ar�His oate n mNteacr wirn rHe rreaeiN Nnn��CONrancroe;o l BUSinCSS On(�PrOFe55iOn5 COCIC�. CONNECi THE A$OVE DESCRIBED ESISTING�WELIING TO iHE PUBIIC SEWER. � s `�-'�:�CI - CONSTRUCTION LENDING AGENCY I here6y affirm thai ihere is a construt�ion lending agenty SIGNEDTHIS DAYOf 19_ ,-► a,�" `"'� �•�i�� - for 1he performance of the work for which this permit is o�'�NER oR OWNERS AGEN� (j`Z�2�--�/� issued(Sec 3097,Civ. .). I nooaess Lender's Name �h_�j'�-1 �t� e 0�-'�1 5�� �{� �oC3��1�3 - Lender's Address�[��e • , � I certify that i have read �h�s nppliwtiq�an state tha�the above information is correct.I agree to comply with all County - . ordinances and State la regulating Plumbing and Sewers, .. and her y authorize r �jresentatives of ihis�County to emer . � upon above-mentio property for inspection p�rposes. _ , �� � -� '""➢� . :r ��� � �'d Signofure o fpermilfee Dafe �— � SEE REVERSE FOR EXPLANATOIlY LANGUAGE _ , . . � _:�-n �.�Q w� :.�n � � m Z� �� 7 ;:,a � . -� ��.� zj vz .u+ on3oz�g: . � . 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