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1561A
WORKERS'COMPENSATION-0ECLARATION -� �. hereoy offirm i'r��t i 'r'v�v�� certiqieate o€ eanacnt ta sel�- � - :� - �nsure,or a c=rnficate of Workers'Compensation Insuronce,or �h^^^Zo � : ocertifie �}, of{Sec.3800 6 � ceeon�etv.aiei) �p�p�F�qTIOtV ��It PE�t11A,iT - � Policy No��Company S�a'�� �u�ld ,�s - ., . . , ❑cP�,�f��a� �s r,�'ebY r��n�shed. _ - SEWER -.SEVIiAGE DISPO�AL ' _ . . . �]Certifed mpy�s>filed with-.tbe county:buildmg=_�nspect�on - eOUNTIYOflOSANGELES BUIIDtNG`AND'3AFETY '= –_`-`' ' department. . . : ._` . . _. - - :.._ . ..-- . ; Dote_�Q�$FApplicant_��_�'�����Tl FOR APPlICANT TO P1LL IN CONNECTION DATA- -- �_�_..,_._._. � �-�CERT1FiCATE6FEXE/J�PTION-FROMWORKERS' -�- - gu!!oi,u� . - • 5� ° �;qTiou pEpTq . : - COMPENSATION INSURANCE � aooeess This Seciion need not be com leted if ihe work involved b the�- ,{�� �Ty� 'pp� r.wN!+,o:e aeFeReNce uv�ER . ( P Y .. .. LOCAIITY ��.Yi!'1�lYL 1Jn.C1 LOWER � permit is for one hundred dollars($l0U)or less.) � rvaeoFCONNecnoN ieN�rN FROnh - I certif -ihat Pr the eiformance of�the�wark for which ihis'� �A�EST . y p - cxoss sr, r. cuae�� a.t.� M.i.ra-P_�. - � permit is issoed,I shall not employ any person in any manner. ��- ---- � . -- .. . . p,�.No,. \ � - �--�-so os�to becoR�e sabject to-the�workers'�Compensation Laws : . . oWNER rr�.+ .�'D�' �i�1 r.o m�a.uo. � �oa No. ��,y✓.�'}"fJ . ` - � N✓Il T t YY,�� �/� Z��[� TRUNK PERhM1IT NO. ROAD PERMI'NO. Date Applimm .. nooxess . .. . (!'$ v � 3 _ p AFFI�AVIT WAIVER E45FMEN7 RECOR�.1NSTR.NO- DAiE NOTICE TO APPLICRNT: If, affer�making this Certificate of�- � {�,Y IY�Y'F�ST£e{'3i_-.�����-Tl�d 8�.� 9�37�75�1 . Ex;mption, you should become subjea to�the Workers': ,tVti�. y� --- .. , 'npensation provisions oi ihe Labor code,you musi 4orthwith- o�5[ewi!oN tOi ND. s f� Hv,�r.ok si.w{oeNiN� .;iply wiih such provisions-or ihis permit shail be deemed' ��r��� � revoked. -- niocK ictncr i StAiFENCROACHMENT - - LICENSfD CONTRACTORS DfCLARATION � "°.°r e�°cs. P�RMiT No._ . .__ _ _� �512i OF lOT NOW ON LOT . - I F.er�by nfifirm ihat I om fi,ensed nnder provisir�ns-o6 Chapter---. �� �usEOF c�'��� 12 ��g.l�.enZs� � � 9(commencing with Sedion 7000)af Division 3 of ihe B�sr' ��. BUitoiaGs �i CHt+eGeS . ness and Psofessions Code,and my license is in full farce and --�^ q�� � _ - 2ffECi. A - GOfJTR?.CTbR ���j�� ��iy�'�� CONNECilONC4ARGEFEE ��. L�cense Num6er 4��t��7Lic Class� `�+�J�- A��R � _��� ���_��pn� -�„� __ eE�MauesEMENi FEE �� , COflifaCtO� �• .l'1-����� OafB vl��✓I'✓� _ JISiRICTNO. iROL'P MAY PROCESSEDBY �'-- . ._aTv .�r7't"i_r3._.��p_���e.No. ar oc �.� ❑!am exempt under Sec �of the LA.Ca�� , uceusE r�o. �t y�$�f Ctn55 Cr ��� -�- �- � -� Alum6ingCodeand/or5ec. _ofihe- N�- �ESCRIPTIONOfWORK Fee F�wFli — id� . r;o�se s=v✓eR mNNeaihc ro onre VALIDRTION � " s.' - 6.&P.Code for the following reason ?v?iiC 5[wEa �. �� r 1—j(�^��, .aa1 � ' Sf4'I C LANK SEFPA(�E Ali(3fi .. _ �_ _, � CI:S AN'J R uRAt(vFICL� +3NAL r^�—-- .., - Date "� �r ��" - No se s�wee coNNectiNc ro _ _ �� � � ' � - -:tiJAi�LSi'OSAESYSiEM $19�tOtUt� __..._.e� - 'O`1NE T DPITIp1AL BLDG.OR � 6WNER-BUILDER DECLARAF7pN � woeK to House s=wEe _ � -� a u � � G✓ERFL W SEEPAGE PIT DRAINFIEID . - ' - I h=reby nffirm ihaY 1 am exempt fro�n fhe Contractor's License��. �.tea_c s,:�oe.,oxYweu,MaNvote , taw for ihe following reoson(5=con 7031.5,Buisness and Pro-- a�rcz,3FPnla oa naaN�on�iaouse�� rt t � � ! 4i � � -k':ons Code)' 'SEWER OR oISPOSAI SVSi[M - . J 1,as owner of ihe property,or my employees with waqes as' � �'k�� � ��' ,l,.`� . their soie compensarion,will do the work and the str�dure�. .. �, - .� � is not intended or offered for sale(5=ction 7444,Rusiness: �'��'"� f �-+ � . - and Professions Code). �� OWNER'$ PBrmit 5 ]. _,�� ,' . ❑I,as owner of the properiy,am exdusively contracnng�with� ��4H�RIZATION TOTAC FEE �g �� �'`'� � ��� licensed contractors to consiruct ihe projecl(Section 7044,-, i qqve Ar rN�s onte n coNTRACT wiTH iHE HEaE�N NnMEo mNTeaciUR!U � � ��-� - . BUsin25s ancl Pro{essions CodCJ. - COYNECT THE ABOVE�ESCRIBED EXISTING OWELLING TO THE PtIBIIC SEWER. � ' � CQNSTRUCTlON LENDING AGENCY - = �I hereby affirm thai ihere is a construciion lending agency-�. SIGNEDTHtS DAYOF � 19� . :, �' for ihe performance of the work tor whith this permit is- Qy,,NER�A�Eh, � �-•e��p:���a,i„> ;6,�,: � issued(Sec.3097,Civ.C.). . �° .„�;�� ADDRE55 lender's Name . - � �� Lender's Address � � - --�-I certi4y thai I have read ihis application-and state ihat the�- - �`c�;' �-. above information is correct.i agree to comply with all Coumy����- -� - ���`� '�� �-�-ord"+nances and State Iaws�regulating Plumbing and Sewers,�:- . ���5=� =-��and�.hereby authorize represeniatives of this Counly�to enter+-� � � "Y!� '.'-:upon ihe above-mentioned praperty for;inspection;purposes. �� � �����,�:; � � �t� �--�Ffl�sw�e,�-- r�'-—�-5�`rrf'� � � ? �, � Signature 4 Permiftee Date � SEE REVERSE FOR EXPLANATOItV tANGUh�E � t y ;� � _�`,_ _ __.�--__-__— _ _. __ ___ �. m z� �8 � : o �� g� � �: �� z � �T zo Tx g �� �� o � s= oy .�;, p� oo ^ '� �9 =� o� L' ?'m rza �^rt � C1n °c °m� �ro �z , O 4� �4 6 ro q � . � ,��,� �+Z nR� 'u' u, � v' r {�o ��� "'�� � � � c� ° 0 � � � � � � �•�m � o� � � N � z � G P T �. .. . �... . :�L'� ..�; ' . .,.� � ���� .,/-' �„t . . ..,, 5. . ... . .. f _� r . 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