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1542A
4'� , -- .WORKERS'COMPENSATION DECLARATION - � � I hereby affirm that I hove a certificaie of consent to self - j�j � insurc,or u certi}icpte oi'"workers'Compensaiion Insurance,or-� �e.ata2n LS i p certified mpy thereof(Sac.380U,to6 C.} � cE w�e`R=v.�iPi� - �, ppl��qTl�lll�: FO�R PERSIAIT • Policy �'7/ ompany_�'� rii]71C� . ��s c Cp - ❑Certiiiedf6 -� .�by furnished ., ' � 3EWG1� • SEVNAGE D15POSAL - � , �ce�ri4ied copy+s filed with rhe county b�Fid�ng inspe�tio� ' C�UNTY Of LOS ANGELES BUilA1NG AND SAFETY deparimenL � . _ oare 8 ZO S�pplicant_T�FreGi48ri FOR A�t'LICANT TO FILI IN SOPlN��T�A�D/17A '� CERTIFlCATE Or'`tXEMFTION FROM WORKERS' euimiNc f sTar�oN o=�tH COMPEtJSATION INSURANCE aauaess � (This seciion need noi 6e mmpleted if ihe work involved by the nv.raHoie aeFekeNce -ow e .�--i � _permit is-for one hundred dollars{$100}or�ess.) - �ocnutv ]�I f certify that in the performance of the work for which th�s � RoSEssT .�,_.,.. rvveoFCOn;necrinN iEN�TypRoh� , ��- i-:� �- permif is issued,I shall no1 empioy ony person in ony manner � Y� CURe a.i. M.i.ro P�. so os io bacome sobject to the Warkers`Compensotion Laws . owNea ���+ ,�Z} '+� �'}� � co.umP_No. ioe n�io. S�'-3� - �'�� /� 'p(�'p 2 n TRUNK PERMIT NO. kOAD PERMIi NO. --3 - DPiG+,__ AP�Jlicant - AUUf2E55 �Wi.;_1NA'J�G�-.. ��8 ^��- � AFFI�qVIi WAIVEk EASEMENI R[C(�Rp.INSik.NO- DATE �� .NO710E TO APPUCANT� It, after making ihis Cerfificate of c�rr .�.'�.e3. Lf)IQ8 ie�.No. j - _ rt p ion, yau should become sub�ed fo ihe 4Vorkers' ��A� �, 'pPnSat pn jJrovis'c�n5 qf/{�e�q�Jo�Co(Ie,yDU fi1V5t{ar{�5W th � �ESCRiPTION " LOTNO. ' tiWY.OR ST.WIDENING �� { ,�hply wrth suih provrsions or this permit shotl-be deemed +� � �2vOkE(I. � ELOCK TRACT r 51A�EENCkOACHMEN� - NO.OF B16G5. PEkMIT NO. � LICENSE6CONTRACTORSOECLARATION - s�E�Fi�r wowon�.o� � � I hereby of#rm ihat I am licerssed onder p�ovisions-of Chapter -�u;F.oF . - 4(commenc�ng vrth Setlior.7O(3Q) f D�vision 3 of the Busi a�iiowc-s s�3121 �..$ �281�@C@11 cr:aaG[s � ness nnd Professions Code,and my fc nse is in fuil force and — �('�p� �t �gq+�� �((}x, y� i . e{feCf. [� (�{] p ' -CrJNTRACTGR LV!'i 1`��L•1ri1V V V lYJ 1 a CONNECTIOk CNARG.ff[ �,. 1 -- � iiCEnSENUnbefT��`�����it.C�aS4���W�pG ApDR�SS 82�����1(+h RFIMBI,RSFM,ENTFEE �.,, ; . COf:ffqCtOf�• �rPiPIDG�Yl GQt2 ��GO/VS} . GITY___,�y�� �jOm�, `iEI.N�. � $ � �IS'RI'ii NO. GRUUP MAP PROCfS5E0 BY - � . . BK aG �" • - � :�l am exemp4 undar Sec. ___,_of ihe LA.Co.. - - � ��� Sa�EN�x� � ss7 ���s c 1� � PlumbingCodeand%or5ec._. _ofihe . No. DESCRIPTIONOFWORR %EE FMA�� -- � � � Ho�se seweR coNNecriN�zo �'J /�/� oare VALIDATIAN � � g - _ PUBLIC SEVJER �{ 4JtJ t�,.�( , � � 8.8 P.Code for ihe followin reason_� � I-� y � ,, SEP IC i�NK,SEEPAvE FI?OR F!NRl ' PITS kNC�.k pnAIN�IEI� � ,4SC -� HCl 5��!VtR C()NNFCTING i0 BY �/' . � PR1VATf oI5P05Ft 5 SfEM �J . . $iynOture_ � COM1N T A07!ilOhA BL'UG.OR � - - OYdNfR-BUII�ER OeCLRRAT.ON � �voRr.o�;o�se sEv�e�z . OVL4FlOW'EEPAG Pli,DRA!NfiELD _� ={ v�F,t_'!. ��ereby offum tha"!am�exempt from fhe Controctor's License - exTh CE5.oot,oerWEtt,�dJ.NHote - � � - Law for!he iol?ow�ng reoson{Secroii 703L5,B�isness and Pro- - dir- k ad,-;a oa naav000-i Hcuse �,�,;�.� y .� C _ _ -:ions Ca(�e)' . SEWER 7R'JISP05At SvSlEht � . � I,as owner of the p!ooeriy,or my emplaye.es with woges as - ,_ _, - j v �,',j� c�, iheir soie compensation,will do ihe work�nd the siruct�re . . is not intended o�offered for sale(Section 7044,8usiness - a o. � t�,�? and Professions Code). OWNER`S �Permit S . ❑I,as owne�of ihe property,am exclusive7y contracting w�th Al1TH��IZATION �QpAL PE� � Q �-'�'_'�'"k-�? �j; licensed coniractors ro ror,siruct the project(Sectian�OA4, � i HavE nT rH:s ourt n cpNrrt,aci vnTH r�iE HER[iN Na,H[o coNrkncroR ro � - �� � 8usiness and Professions CodeJ, couNecT THe neove oFsczieeo txisiw�oweuiNc ro TNe vueuc sewea � . ���� .�,(!�� � �.. � - CONSTRUCTION LENDWG AGENCY - � !�herehy affirm ihaf there is a co trvctior� lend+ng ogenty � ��GNEDiNiS��DAYOf � 19_ � - W . for the performance of the work nfor wh�ch this permit is owNte oa f�,�y.4 ;b . . . �'�� issued�Sec.3097,Civ.C.). owNexsn:,ervr �=� �'� � ,�;� ' .ao�eess � � . . - � #! -Lender's Name_ _ � - � ' - - .- � Lender's Address . �� � � � . ._ .. 'y�- _ I ertify tha� I have read ihis applimtion and stofe ihat the - � :r�.- o6ove information is correci.I agree to mmply wifh all Counry ' - � - - -� " ordinonces and State laws regulotingPlumbing and Sewers, . - � �and'nereby o�ihorize representatives of this County to enter . - :_� - -��,i ..upon the.r6ove-mentioned property for inspection.pvrposes � -- .- _ - ;���, ��-P/1�,/y'� �� k;QM`tf �•�-��''�'�, ��` _y-�✓�--{-�' $ignplure ot'Yermieee Dote � 3EE REVERSE EOR EKPtANAT02Y CANGUAG� - � � u-,. _:.. . .. . . . ..._ . _ �.,_�. . . � . .. _ .._ . 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