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1550A
- WORKERS'COMPENSATION DECLARATION � � � �. . . I ��e'eoy �<'rc "c Lcve c cer'�`icar�c" ccrser�lc se�i - . � insure,�or a cer'ifimfe,of.Workerd Compensation Insurance,or .� -�bAba2D - � . , � acertiiied�e4..�Sec.3$Q�./.�L� �un� ce5u8(REv.e�ei} �pp`��qT{ON FOR PERMIT - �� . PolicyNo. f4ompany bcLb - �5 . . -SEWER --=�PW�GE �I�PO�A�:- .;. . ��: -' ❑Certifie p is herekiy fumished. �� -- �� � - . " - -- ��- - � ��� `' � ' �Cerrified copy is fiied with the county buildmg inspen�on �OUNTY'OFLOS ANGELE$ ` $GIIDING`AND SAPETY -' - � _�epaft ent _ _ � - --t3ate._� ..Z�..�.EiAppl+can� T• F�GP.IAd.A ;.. -FOR APRIECANT TO-FILL IN: - - ,CONNEG'TIOPtDATA :; � CERTIPICATE OF EXEMPTION FROM WORKERS' ' � � ����� � ������ T � . � . - - COMPENSATiON WSURANCE :> ncoaess ��-� "' . � � - � � STAiION DEPTH _ (ihis.sec(ion need not be;ompieted if the work.involved 6y the -.�_ - � . r�nNHO�E REFEREnc� . uPa�R � � oermit is fm�one t�undred dollars($100)or less.) � � -:� �ocaurv � tOWeR . �, - NEAREST . iVPEOFCONNECTION IENGiH_f20M � : .- 1 certify)hat in the performance�of the work.for which this ,:.. -- c2ess sr. _ . T- - . v. . ��Ry P.�. ,v,.i.To-a.t. � � permit is issoed,I shall not employ any person in any manner`s: ` � - . � so as to bacome sob ed to the Workers'Com ensatioa laws. I� (e p�'[�} a.c.Na )� ,,�� I P -- CWNER y�� ��� VT�Q�1P CC.IMP.NO. )OB NO. { .. - - MAIL �p/� r�(� � — `J � AD�2ESS �O 13V����G 7 � TRUNK PFRMIT tJO. ROAD PERMIT NO. _ Dp�C A�Jf?IICqf1�_ A�FIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DAIE NOTICE TO APPLiCANT: If, after making this Certificate af �� arr (�,.OY3I1�. ift.r.o. 8I� �j-+ � � --F��Ymption, you should bemme�suhjed to�the Workers '. . IEGAI _ ��ipensotion provisions of the Lo6or mde,you must forthw ih ` .. oesreivr!oN �ot NO. �Hwr.oa sr.e�ioerviNc -� .fiply wifh sucn provisions ar this-permit snall 6e deemed � �� revoked. � �� 3LOCK :RACT STATEENCRO�tCHMENT - -�'��, LICENSED CONTRACTORS DECLARATION � No.oF eiocs. �'kry+.�r No. _ � � SITE OF lOT � NOW ON LOT � i hereby af¢irm ihm I am tieensed�nder prcvisions o-F Chapter r �E oF � - 9(commencing with Section 7000)of Division 3 of tne 8usi � eunui�:cs �2I'1 �.� �.�S1C�8T1G8 cNna�es - - � ness and Professions Code,and my license is in full force and � — � - CVN'J'eQtON CHARGE ffE � 2ffCCi. k�7 �g � AN¢r\^TOk - 1 -_ ..� LicenseNum�er.`�r�"s`$��_Lic.Class��� AD�RESS ��� �e�yyTj�QQ(�, ,�" REIMBURiEMENTFEE �5"}. (, p� p r�/� p! ���_..,__ ��. Cpntr�GfOr1m �Z'��PdXl �ate V/GV 4JV_ Al.L� �� _ DISTR'CTNO. GFOUY !MP PROCESSEUEY _ GTV ��,.�� iEl NO BK PG � � .� ❑I am exem t uhder Sec. of the 1.A.Co. � � STATE p u�. l d .� +� . tiCENS NO �� p CLp55 �- Plumbing Code and/or Sec � � � of the N�� DESCR P.ION OF wORK fEE FiNAi ��.� 4CUSE ENfR CONNECTING TO OATE VACIDA ION kL - 8.&P.Code for the following reason PUg��CSEWER � �d ��—��� �� . - �:_ SEPI.0 IANK,SFE?A6E P1T Ok -�. - �FITS ANJ1pR ORA�NfIEtD fINhL . �qiB HOJSE SEWER CONNECTING i0 Hv �F. '� - Pxl�Ri�LV PCiSAL SVSLEM - Si9nafUre CONNECi ADD.TIO4Al BLOG OR -- - --� �: r*'. OWNER-BUItDER DECLARATION woeK ro Ho�se sewea , � O'vE4FtOW SE PPGE PIT,DRAINFlEtD � :•, y . p � nuNHO�E _ �°?.: .. -', Lawrfar the follow nga asore(Sect n 7D31 S,�Buianess anld Pro- I ir R-tvna�oe:ana oor+HousE� � - '�' � ' - k� ' Siuns C�de�: ' SCkYr��CISPOSAI SYSTEM . _. _. � 4 C�i. h�.t - . . . .,... . . .a i ?I,as owner of ihe properiy,or my employees with wages as � Iheir sole compensation,will do ihe work and the structure . �%'�}° °���`� C� j - ' is not infended or otfered for sple(Section 704A,8usirtess - - � � � and ProfesslonsCode). OWNER'S Fermit S �. :� �r a�. �7��; . . '�'��? �I,as owner of rhe property,am exdusively comracting with ��1YHORIZAYION fQTAL FEE _ ,� `s �icensed contractors to canstruct the project(Section 7044, i Have nr rws oa?e n couTeaa wnH rHe HeaeiN NnMeo co�,vreactoa ro - � � v ��� ` -� ` ?' . BUSiIt255 O11�P�ofeS5ion5 COfJ2J. CGNNECT THE ABOVE�ESCRIBED EXISTING DWELLING TO TH_PUBLif$EWEF � y'T� 's� `S� C�:.���F � CONSTRUC?IO�f LENDING PGENCY � ../"- p/ �� " � � SIGNEDTHIS � , DAYOF �7 19� � � I hereby affirm that ihere is a mnstruction lending agency ',, y:: . ib � GYJ4ER OR � "-�- ' _ . far the performance of ihe work for which ihis permit is �- < � : OVJNERS AGENT issued(Sec.3097,Civ.C.). ,5� . A�DRE55 � "#�:� Lender's Name - - -�1:'� � � lender's Add�ess � �- � �`"� � J certify that I have read ihis.application and state ihat the � . - . '- above informaticn is correci.I agree io comply with ali Coonty ', - � � . _� ' --�ordinances and Siate IQWS regulating Plum6ing and Sewers ' � � . � � % � and hereby authorize representa�ives of this County.to ente � - �� -�opan�1+e above-mentioned property For inspeciion�purposes � �,�; �_" � �,�4mtit;�.t.— Sr-�-�'-�"� �� - Signature o Permiftee Date . SEE REVERSE FOR E%PtANATORY LANGUAGE �- � - ' "� .... . � - � ... - " . :�,i��. 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