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�'��� '� WORKERS'COMPENSATION�DECLARATION- �- '�. .. � . ��� � '� I hereby affirm thai�I have a certificafe of consent to self � � � - � =- .,cinsure,or a:certificate�of Workeri Compensation-lnsurance,or'.'�: '"" "�aaenso -- � - � --.� - . � a�e.t,f�e . f�5��.;38�,�ab�.>: �t e�d,krv 8,8„ _ - APPtICAT141� FOR PERMIT :. folicy No'��Company ..���3'�8 }it117C� �� . '��s .. .- .. .. . _ ...- n -�.G ce�f�f����tn�bY:r�,��sr,ed � SEWER - SEWAGE �ISPOSAL ��' `�derafjtmenopy�s filed wilh.the county bu l,lir.�.anspection C�UN7Y OF'lOS ANGELES BUILDING AND SAFETY "' "6are�!`Z0 $6,4ppl�cam_�a �`Z_+'P@ttT[I1I1- FOR APPLICAN7 TO FILL IN CONNECTION DATA ' _ __ CERTIFICATE OF�EXEMPTION FROM WORKERS' � �- ewianc - � / - � - �""COMPENSATION INSURANCE � �� noosess P 5*nriarv oevTH . s Y- �.This section need:not bexom tated�f Ihe��work-:imolved b tfie- �=�aN� B� ur�ER � � 2 N- "-� . P = '- Y - LOCAiITY MA`1HOtEREF:RENCE LOWER ' �+�� -_;permit is for one fiundred doltars{$t0p);wr lass:) .' - -- 3= - ; NEARE5i j.� tYPFOFCOnNECTION IENGTNFROM - ' 7 " �l cenify tbat�n:the performante of the work for which this �� . ceOssst.� c�� v. cues ei �n.�.rovi. � � =',�permit.is issued,�fshall no(employ anyperson��in any monner'��� - ' ec No. � �so as to bemme-sub�ect io Fhe Worker.s'-Compensotion Laws. � - .owaee ���+' +���'iN �T.�'��� � � co.itvia.Nr. �oa r.�2 .��'�`j ,. _ �: � - �' MAIL �O �=Y n TRUNK PEFMIT Np. ROPO GERMIT NO. } 3'r; _[��tC App�ICan} . .. ADDRE55 rs w -.- : . �� "�nTICE TQ APPLICANT:=1f, after-mpking,ihis,Certificate of - �Q[���,�, ,E�Nc ��..� 96��� � n+Fio.awr w.aivEz ensEnntNr RecoRo.wsu.No. onrE - �` -. CIiY . � �' �. ,q"e ��^.mption, you.,should.6ecome.su6ject_to.ihe :Workers - � tE�at - -�-�� " - �� � �pensotion�royl��ons ofth'ealQbor codez,You musf�forthw�SF���.�;� _�� DEscaivrerw ' " :�.Lorriio`"=��= "'��_ �-���'""`�'=u' '' . - - - v.. �... ; -_. . rtw�oR sr.wioE�vw�- : � ;�. �__,nply with such-provrsions or this perm:i?shall be deemed jj __.__ ____...,. . ,':tevOk2CI. -� BLOCN � TRACT � "T SiATEENC20At'HhIENi . _—NC:.O!&LL'GS. — PE4M1{ii iJO. � �� LICENSeD CONTRHCTGRS DECLARA7tGN .. � sireoFior niowoN tor � �- -1 hereby affirm.that.l am licensed vnder provisions of Chapter - .! „sF�F . '9�(cornmencing with Section 7fA0j of Divisiort 3 of iiie Busi-� `: euuowr,s' ]„ u cr+,qRc�; - ` � �ness ond Frofessions Code,and my iicense is in fuil tor<e and�.: — —�--- �--- � ' � �effect, - � corrtencroe cQNNeaioN ckauee he ,g-_ � liwnse Nombect�B.��� �ic.Class �(��j��(d � �� qDDRess 8`�2 ���(j��t(Q�(i J}�,'+ sei��nauasenneN,�ee � . ..COniroctor-�� �re��a� �CitE Sf 2VIVU _ .� CI!Y hyf�a. �IDm�._,_ iEl.NO. �,�,�.���Q��_��[/} �ISTRICiYC. GROUP MAP PROCESSElBY - SiATf ��� " _ j flK PG ,Z,. . .�]I am ezempt under Sec. ef the L A Co - -� uCerase Ne. aA55 ,� g� °'� No. DESCRIPi1�NOF'JJORK �'e �: � Plum6ing Code and/or Sec. of t6e - _� '"N''� l{`�� l�b :VALIDATION� ��- � -- hI0U5E SEWER C1�NNEC'IYG TO 'DA'E � B.&P.Code for ihe£olta.ving reason eue ir sewea - - SEPTIC�ANK,$EC AGE P!TOR . ..�: FlTJ ANO/OR�RAINF_E.0 FlNT,L . . _ _'___'"__�OtC HOUSESEOY2k ONNECT:NGT:i '_ — Bv �� - . PRIVATE OISFOSA�SYSTEM � � - $ignafUPe _ _ CONNECi ADDITIONAt BLCG.OR � � OWNER-�BUIIDERDECLRR,4TION weRKTONc�sesewEk _ . .. � OVERFLOW SEEPAC:°R ORAINFIEL� � �;I hereby affirm tha?I am exempt fram ihe Coniractor's l cense - _x:N.,cessPoot oavwe.,a�s.ut+.o,e � .. � . r �,_��r .-.. �law for the following reason(Secton 7037.5,Suisness and Pro- � taiek,keanie oe Ae,4n;ocN Nous� = �• .- � ' - - � , � . '*;� . -. ::. �wes eR r,i<��i srsru.� , - - s, - arons Code). . ,. .,: .._ ::_ .:. . . . .. . . .'-� _ - ,_ ( �� ._ _. , .,:.� . . �:-.. , .�.:... , _�:#�-;fi o.,�"�.�-�r) �- � `. .I,as owner ef fhe property,:or my employee.,�vrth wages cs ' _ - k - � their�sole compensotion,wfll do the work and the siructure_ . _ _. � -�f�;e^�!,�;f�� � t is not intended.or of?ered for safe(Sedion 7044,$usiness � � - � � i ' � and Professions Code). � � _ - OWPIER�S Pefrriit 5 �0 Q - � .-a ��... �.-c � � . - . . .._. . _. _ -�- .. _ ? :. teu _ . • �� .❑ I,as owner of the preperty,am exclusively-contrading with � -AIJTHC?R{ZATION-, 7(�7A�PEE- `Z7 Q .. -- L� ... . � licensed contradors!o constru8 fhe projeci(Section 7044, � _�HAve Ar`H:S DAiE A CONiRAcr wrtn me�aeREiN NAMeo COMkncroR io - � :G$3�:.. ..'�l'C - � BUSine55 ant�P�Ofe55'ton5�CO(jE).� - - -CONNECi THE HBOVE DESCRI6ED E�IS?ING'JWELLING TO THE GUBLIC SEWER. � � � . - - � � : � � -- .CON57RUCTION�LENDING AGENCY �- : � 1������'' . :,, � � � for theY erformance�of�the��wark for-.w � �nding�agency .SVGNEDTHtS�DAYO� � 19� , � � I hereb affirm�that there is a construct _ -�WNER OR -� � -:-: . ; ' p �. hreh th�s-perm�t is-:� .owN[asn�eNie^ «. 9� 'ft,�� . .... � . ;_.�� issued(Sec 3047,Civ.�G). . .. � : . � � . . � . -. - � . _ .-. . �.-�.- noraess. �.� 1 3 r � � ...,- .�..-. .. . . . . .. " - �Lender'sName-- �� ' . . . ... _:.. _ _ . � � _ ' . tr. �. Lender's Address_ ,_ . . � .. . � . _ . . � _ - ..�. � . . . ��. . � i certify ihat I have reod lhis application and sldfeJhat the � .,_,:, .. � . _ __- -. . . : ' above infoimation is-Correct.I agree to�comp�y with'a(f County ' -�` � � '-- � --� - � ` � � - -� � ardinonces'and State-'laws regulat(ng�:'Piumbing-ond-`Sewers;' `- . .. ..-. . ._....'.�. . . . . . . ......-._� . .. .__ . � . _. �. . ., , __._. _._... _ ---. � and hereby authorize`representatives:of'ihisCounty:to enter-- ' � . "` "` . �. .��- . � � � . - �� . -- , upon ihe abDve-mentioned property for inspecfion purposes. � � . . � . � �� � . � - . � . - . ��1�'✓��,�-d�t s�/wtr�.���"b�� : _ I-�. _ Signatoreo4Permrffee ' �� -�Dafe _ -__ '- . 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