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1541A
1' WORKERS'COMPENSATION DECLARAiION � �'t hereoy affirm that I have n certifimte of consent to self -�insure,�or a certificate of Workers'Compensntion InSufan[e,Or �"76A692D . � .� p�e,;,f ea��f fse�:38�,cv�.akb�.,�n �E eoe�REu.8,e�, p►pPL�CATIOt� FOR PERMfT � �. Pol�cy N Company_��.�__.y'E117,(j O"s � - ❑cerr�+ � � r�,eby+�.�rshed. SEWER - SEWQ.GE DISP�SAL ;:�Ce�tified copy is filed w�th the<ounty bu�ldrng inspect�on COUFITY�F LOS AN("aELES BUILDING AND SAF@7Y : department �� � - � Date � 2O 8�ppp�i�om T. �+'Z F?9ll1aY2 F�DR APPt1CAN7 TO FtLL IN CONNECTION DATq _ CERTIFlCATE OF EXEMBTION fROM WORKERS' -� ewioiNG � COMPENSATION INSURANCE ; aooaEss STaiiON oee�N - �'3, -�{This section need-not be-completed if ihe�work:involved by ihe ',� i��q,iry s � traNHote rteFeaen�rF uavea . s permif+s.for one hvndred�do�fars($100)'�or less j�"� . DI � �� � � �OPJ:k ' �,NE4REST 7VPEOFCONNECiION IENGTHFROM . 3+�. '--1 ceriify that in tfie-performance of the work�fof which ihrs _ � ceoss 5T. � C�i v. cue6 v.�. M.�.'o F,i. t+- ,permiYis issued,}shall not empioy any.person in any manner �ap� (�'pn T�- - SO-aS.tO.beCOiT1e5U��eC�tothe-Workt'rs-ComQenSationLaWS '�pyyNER �K� ��111Y LTi\VV.L CO.IMa_ND. J�NO� ��.-�� � ��� -p����;� p � iRUNK^rEkMli N0 ROAD PERMIT NO. .,. Oate __-_APPlicant nourte55 p� �.��.1�—__�—_� � . °��` -.�NOTICE TO APPLICANT: If, after mokin -this Cenificate of � - .aFFionvm wavea eqsen+evT aeCoao.iN;Te.rvo. onre � � g- r F;_ ' � .> � CIiV � 7EL NO. � .... . . . . �*;_ ,>.� mpnon, yqu_shQuLd FiQcome subjeeL to the.-Workers .-,-- -���tEGn ��'� �' � . _ .. --- �� -�- . �4 �ipensotion.prov sions of the Lo6or code,�ou.:must�,forthwrth�.�����,a:. oEURiPripN-*--�-�-�=toTNo"">'� � Nwv.ca si.wioErt!n� � .,nply wdh s�ch provisaons-or ihis peimlt 3half be deemed �� �� _ `�EvoicPd. _ . BLOCK iRACT __ SiA'EEhCROACHMENi - ND OF�LOGS. �� G=RN,ii NC. LICENSED CvNTRACTURS QECLARATfON - szeof ior Now oN ior ��� ' � f a; -i here6y offirrn ihai I am licensed under provisions of Chapter . �SEOF — � .� :4(commenci^g w�ih�5ection JO(70j of i7ivision 3 of tFe Buai � 6Uao�Nc,s S�-5�1��-� �.e$1f�.E,'37,C� "-- -"--- � :r,es;ond Professions Code,and rc�y ticense is in fu41 force and . __ cHa.rt�es eftect. p�(/�o p�''] �[y� ('� � cau�vnc-oR�'Zn°££ffi3Yi- {"i071.`J���]`3:t.��'y_t„..�DYl .. on��c���,nc�az-e=�� � , LiCE1158N1;rtiF3Ct YI4VVf Lic.CIOSS St3Yb. E��I . �. AQCRrSS SJGZ� B��C�WOC�LL LSs i REIMBLRSEMEYTFEE � � . Con9faCtor 1• �����`hAte .....'✓�/��U/�43_ - - QTY�'tGj, �°� TEL.NO. � DISTRICTNti. GROVP gK MAP G :vRUc'ESSLDBY � �,Are 4'74�87 �:c (;34 �`�_1_� � �.❑,I am exempP under Sec. � �,.__.�oF the L k Co ,iceNse r:o. anss ; � Plumbing Code and/or Sec. of ihe �� �n. DESCRIPTiON OF lvORK Fee F�N�i .. � � �crs s�wea coNNea,nc�o �nre V!lLIDATION ' � -� ��� 8.&P.Code for the fol�owing reason_. PUB-icsewea - �� Q� � i. ��...,�6 -_ __ �� SEP,IC A^3K,SEEPACE PIT CR 2 �iNpl �� � . P TS Ah DiOR D�AIN IELp . --Dd�e HOUSE SEl3'ER[C�NhFCTIIvG In ��Y � � PR YATE�4POSAL SY�cM � � Sig�otu�e _. _,_ CONNE i ADCITIOhAl3'.DG OR :,� � . - �OVVNE�-BliIL7tR L�ECLARATION voa��, o Hou�s JeEe _ - �� . . . � OVfRFLOW SEEpqGE P17 ORAINFIELD - + -�t hereby aftirm ihat I am exempt from the Cont actor<L cen Exm E 5-ec_,eRvwEu,n�wt�Hote . � . nw ` -Law for ihe foflowing reoson(Sedon 7031 5 B�sness nnd Pro -: wrea.Re.aru ow neA�i9orv aouse ^� — -�-��. �:; � �ts,�j.jz ,� . cipns CoCI@J: ... ' '- � ��; 4 - SEWER OR DiSPOa4L SYSTEM - �..W.0.:� -.� ..+� ..�:,�w. � . . .. . T- _ " � r a, tl �- - � I,�dsowne�offheproPertY,�nrm/employeesv✓i�wagesa_ � � � � ����� . � iheir sole compensation,wi�l do 7he work ond the stn�cture � - � -- _ - - � � - is�noi intended or offered for snle(Section 7044,6usiness `f � '�'=-s� : �.- : and-Professions-Code), � � � - --- --- t� - -OWNER�$- Pe�mit -"��S �Q Q � � � � . ��❑1,as�owner of fhe property,am exclusively coniraciing wiih- ��THORIZATION TOTAL FEE 'z� Q -E �'`} ':" � licensed mnPradors to mnstruct the project(SeUien 7044, 'y HqvE ni rnis onre n coNraacT wirtf rtiE HEa[w NannEo coNTRACToa ro .y�� .±(:���( t�.�, ' Business and Professions Code). . :, ;�oNNea n+g neove oEscei�o exisriN�ow�uw�ro Tr+e v�euc sewea. p CQNSTRUCTlON LENDING AGENCY i , �1 here6y af{irm'ihat there.'is�a consiruction lending agency SIGNEDTHIS�DAYOF � iq� ��..for the performnnce of-the work for which this�.permit is:. owNeaoe . J�,' �!.��;�����._ � `ISSUP.d{$eG-3097,Civ.C.�. OWNERSAGENT C'�� �--tender's Name � : ���ooktss . � -Lender's�Address � � . ' �.�' i ceriify�that t have.reod this app6calion and state Shat_ihe. _ � .... . - �� a6ove infarmation is corzect,I agree ro�camply with all Couniy�. - --� -- - - � i�; ordinances ond�Slate'-�laws regulating�Plumbing'and`9ewers, ' � � � � � l t'�� and.hereby'puthorae�repiesen�ctives of this'�County to enfer - � " �- � � �� -� � - � � -� -`�- � �� �` - - - � S � upon-the above-mentioned property for inspection purposes.. � � ) g a��.�y1 QSf.*.Vtt°,..31_/___�^'�-"�"�"�� i Si�e fA d-Permiitee�- Dofe _ � SEE REVERSE FOR EXPIANATORY LANGUAGE . 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