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1543A
�i, WORKERS'COMPENSATION DECLARATION . � ��- I hereby offi�m ihat I have a certitimte of consent io seif -- - � insure,or a zert"rficate of.Workers'Compensption Insuronce,or - �6A�n2o r. Po��Y;�Q�'^7���osmP���t`ate' �u�a _ .: �80e`�E�8,8„ _ _ APPLICATION FOR PERMlT �" -��Cert fieB�p��.,�eY'eby furnished. : ' - '- - - - - �.�EWER--SEWAGE-DISPOSAL � � . �.. , �' Certif�ed mpy.is filed.wifh_.7he.cour�ly_buildi�g:inspecl�on COUNTY OF LOS ANGELES BUILDING AND$AFETY ':. .- department ... . . . ��� . � :. . Dote � `�g ��pplicanr �• '�.'+2"�$€ed23 _ FOR APPLICA19i TO flLL IN CONNECTION DATA '�'` . CER7IPICATE OF EXEMPTlON FROM WORXERS' ---- .y�. .-:. �-. . _... �' .. eU1L�JING ' . . �".COMPENSATION INSURANCE � aoceess -� 5rnrioN oePrH - ",(This secl on:need nat be completed�f the-work imolved by the TT d AAfITTIl T3 p-n UPPER �-��� _permit is for one�.hundred.do{lors($100);�pr less:). .. _ ��` tc[nutv 1�11if-Fvtr1� ��s1a1 tu`NH°`E REFERENCE !oH�ea �� NEFkEST ' TY�OF GONNECTION LENGTH FROM '.; l certity ihni in.7he performance af!he work-for which this . ,. atpsss. � v. cuka a.�, .. t�n.i.tOv.�. "� -:permit it�ssued;.l shail notemploy any pevsom'rn any manner �-=---- � ______ --- ' ' so�as;to become_subjectto�the Woikers`Compensption Laws, ,- �f�� �D� �r�- P,c.No. .. . . .. . .. _ . . OWNER CO.IMP.NO. InR NO. .V�fy _- ADD�ftE55 S V.STV✓1' . G TRUNK PERh�IT NO. ROAD PERMIT NO. . Daie Appiicant __ _ - ... � —_____ - ,;. -NOTICE TO APPLiCANT: If, afler making this Certifimte uf �- ���y 8�� aFFiD�vii niv- 'sennF aecoco.irvsiu.No. oaie � W Erc cA NT GO'�a.Y1�. TEl NO t a .�c �mption, you.,should become subjectr to the,Workers' iF�A� — - - ���_ � . � - �; �pensofFon,provisions of ihe_�.Lqbp tode;�yaulnustforthw th� _ � :oEscatarla�t =-�C+�xl*'"--*�,s-� - -- - HWv.oa ST.WIOE�uiNG � - � - `-` ..�.;., .�.�_.� ,.:� �.�.. _:. .. s, . 3 .,in I •a Ih such rovivons or th�s ---- - :��. � Py p permit sholl be deemed �G��� _ ______ �� �revoked. - aixK ra.�cr � S.Ai:FN:FOACHMEN� �� LiCENSED.CON7RAC7pRS UECLARATION No.oF s�ocs. FER,V�ir uo. - SfZ:OF lOi NOW ON LOT —"-'" �"" � I he.eby affirm that�l am licensed�nder prov�sions ef Chanter . uSeoF :� -�9{commendng with-Sectien7000j-ot t�ivison 3 of ihe Bosi-� ��� sUaO!NGs �,�`127��E" E � I1 Gy.au�,rs � , -�ness and Professions Code,and my license is ir tu{I torce ond -��"--- �.effect � -- mNtaacroo ry �corv�ecno�u cHAece Fee � - License Num6e� --- �� ,. q�'7��}p�'} , , � ' . . � : ' ____.'#1.y-V5J_j,�IC.CIQSS �:� . AD`�RC�; ^ FEih1l3tIR5EMcNT�EE - q 862�f�36 °' Ccntr❑cror �e �'�t?BIIIc'�T1 Date ��T.y ��Na o�srxici Nn suouv M,�P PzoG�uEo By c<a �. STaTE BK PG � ''� - � ❑t am exempi under Sec._ of the L A Co ry °i� � � �- �icEr�seuo. c�ns& ('��� �� � . ! Plumbing�Cadeand/erSec. ofthe ��� DESCRIPT,ONO WORK FEE .FiNAi .____ _. � } . � —�_—_— YGVSE SEVJER OM1N T.'�G iG . �' 'nQ '._ ��`'�'�� > - ' rueuc sewea � °A`E VAUD TION - "' -� , B.8 P.Code for ihe following recson u � . � � � - � SE�`��C1ANK,SEEFAGEG'TC�R � { � D�fe Pli AND/OR ORAIM1FIE^6 _ BI�NRL i . � . � � - -FUUSF SE�NER CO`lNECTING t0 ��. . � . _ PR VAiE DISRQ4AL SYSTE+A Signature — ' f j CON\ECI AO�IT.CNAcB,D6 OR - g� - OWNER-BUIIDERDECtARATkO\ w ser,Housesev�_a . , . _ W RflO`N SEE AGE PIt,DRA NFIEI� � �� � .i 4.}ji �I hereby affirm ihat I am exempt frem the Contractor's Ltcense ,. i_,�ssP�t,�evweu,NaNHote �-- -law for the foltowing reascn(Sc�cion 703L5,Buisness ond Pro ��Erea,aepa!k ex nsnrvoorv r+ouse _� � � SEWEROR�ISF`OSAlSYSTEM .iY y � gg� .ions.Code); . .� . �- ..�.. .;:-r�, � . . . 'sa` m. `-._,�J,oshUmerof!heproperty,ormyemplcyeeswi?h�uic,gesa.. � . -- - .. � �:�"� � �'�- � . � iheir sole mmpensation,wi!I do the work and the s'r:.�cNre - � � - � " �- � - is not inFended or offered for sole(Section 7044,Business � ,� �„���v -_ ond Profess�ons Code). �WN@g'$ Permit 5 ]_� rjQ � -.[�F,as owner of thc propeity,am ezclusively.mn�racting w'ih ��A�1THS�RIZATIQN -7QTA�FE@ . "�'] CjQ � �.r_t'�-';7 v .�icensed-�controc#ars to construcf the projeci(Section 7044, .�NaVe ar nll;cArE A corvtaACT w�rH iME He4E�Y NAMEp c�NteAc'oE io � - B�siness-and Professions Code�.� ., --CONNECT THE ABOVt�ESC4IBED EXISTING D1^/EtLING f0 IHE PU�LiC SEWER. � - � - � -� -- CONSTRUCTION LENDING AGENCY �''" g� � - I he�eby affirm.-lhai ihere �s-a construcfion lending ogency � SIGNEDTHIS '�l DAYOF � �g � � �� for tfie performance of the-work for-which thF§permi� is �oWNeeoe ��rt� j_�gC.��, � . - -�- - � � � � :�issued($ec.3097,�Civ.C.). � . . . owr�eesa�eut ��=-3 . . . .. : .�qDDRE55 � Lender's�Name-- � F-�� Lender's Address___ � ..� ' . . . . . . .... .. . .. .. . �. �. I ceriify ihaf 1�hme.read ibis-opplicoifon and sta?e(hat ihe� �' � � � - ;� above`informafion is<orrect't agree to�comply wlth,o11�County. " �" ' ��� �� � . � � - - .�-ordinances and State iaws reguluting;Plumbmg�and-Sewers;� - � - � � � - - - and�hereby authoriie�representatives�oT this CouMy_�io enteF -�� �7 - � � � -� - � - � - upon the a6ove-mentioned propeFty f�r inspechom.purposes. � ` � - .�-� ��l�•A 4 9.w4'iG..c/" S�"""M?'-4'-,. ' � ' .. .. � $ignaNre of��ermiitee> - :Uate . � - - � �. . �SEE REVERSE FOR B%PtANpTORY_tqNGUAGE. . . . .. �____� _. . __..,. . .._..m_ w_,..... �;:..:�._..,.. ...�ym .v....:�.�,.,:a_�,.�. �...���,.. �_.,...: � . _.� ,.� �,. ,�,� �A ��'+'�;�'a � °es°'•a a<��' � �° o��+.��m.a ., ...M w.f.�,.. ., � „� ..�.u� �� �+ � "^� � o ��ro �' �� �'� �+'�o � rC-'.��° m w a'�a' a. . . vy � a. pti �� y����w�Q.� d:.,��6, �':4 .. .'� O�i � �.Oy� . . ,. . . � . .' � � y.,,,�+vt � O � 4i p`w O � {C, � py cq� . . . . ... .Q,p � ��" �'`.'.� �'�+�� 9d� .,�&�'sm� p r�a'q . �7 e.`�'w,*..° Ci � 3"'. �� °b' � � � � �`"t� � ��� �� .. �... �'� �W° �:°� �r .Y "� �w. �.sCs"y 0^e" a�a��.� *s:"�.�,��` � . �"' ����_,�"�^`������.���.. ����.`����^v W�,�. _ , y ap, � �w � � `�C ��r c' cT ��q 9'�. � �.4.,..� � � �� � �� t�� °'.�� �°�a�`67a�"" 2�� � � o�Ct"" C9 "'n� . � � °`�w �. r,.�g�l��� � �a �+u �� � � � � " Ci �.._ a� �� y��m°q.r�"'�;� '+ �V"��� �D � � �tl.� � a.� 9 �1:1 �-ak'�`�g�"`�,� �� . �`e er t3;; �'.•�.� .��,g'�wo,.���m�, a���•�c.,,� �' � � � � � � m o „� �'v'° �'� �.°c C �• ��,� � , a,� � �o, �,•�a �; �°�`°;���� ���'���� �.� � ,� i� „'°, � � � �,� � �'•�'�o���.�� � � � m �� : . �. � °����e�.�°�5a„���� � � °a ���,��,� � �.� � a �, � �� �,�� �i,"�' ���� �� � ��� ����°' 'm,a� �.—;, �' � � . � ��� a �������,�� � ����°���,���� � � a,� � cr+;. • �,'� "� a,�, �.a °er",,q �� � a s oaww c1. �1a � za e.i m � � � � w,�Zy +W�^d- �°� a � � yy . � � m ��v �E't3 � � � � � n�a '� �a7�'iy i�"�. a� �D�� � `�' �. g�� � � ''aA.-<. � �7 �^�^ O mF"� � y�aa m",�,,s�* � aa py �, �. . 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