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1549A
- � - - WORKERS`COMPENSATiON:DECLARATtON� � -- � �`- - - -- -� - � --� -� -�- � -� - '�- - - - - - - � � - ` - � I hereoy ase�irm tnoi I nave a certiticoie or conseni to seie . . - � � inwre,or a certificate of Workers'Cempensation Insurance,or � . .�aaaaso . � . � ; a certified co 1h reof(Sec.3600,Lab C.) � ce soa�aev.einti �pp����Tt�N�� FOR E�ERMIT - � P I�cy N :������a��ompanySti. _�'w�.d -; �= SEI�/Eit - SEYVAC�E DISPOSAL � - � ❑Certifi d cop s hereby furnished. ^ . � [�.'��t�iied copy is f�led with the munty building inspection - COUNTY OF LOS ANGELES BUILDING AND SAFETY deparfinenL � � -- ---- ; __ Dare__$ 2O _�licant. `i'• I''�'f.'EID2I) FpR P�PPLICANT TA FILl1N CONNEtTION DATA ". CERTIFICATE OF-EXEMPTlQN FROM WORKERS � uui�.uwc • sy r StanON oEVTH COMPEN5ATION INSURANCE �� �nD�rzEsS f.e (This section need not be completed if the work involved by ihe "� � ���Q�� $ 1,h4Nhiote aeFeeervice uPr`R � � permitis for one h�ndred dollars($100)or less.) � iocni.irr -. �owea NEAREST � TYPf OF CONNECiION 1FNGTH FROM � 7�certify ihat in ihe performance of-tke work�for.which ihis.-- �uoss 5i. ��- y. cuen p.i. nn.�.To a.t. � �- permit is issued,I shall not employ any person in any manner - �� � �— -'��--�� � � � ' so as to 6e<ome sub"ecl�t6�the-Workers'�Comoensation Laws. . P-�-"�� 1`�'"�'" . � OWNER ���j ���j� ��. �CO.IMG.NO. JOb NO. - �ORE55 �t,l }}�X' G . TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant � � — NOTKE.TQ-APPLILANT::I{, afPeY-�naking..t�tiS Certifimte of .. ��TY Ot O [�C�7e ry /+fFiDAVIT WANER EASE.MENT RECORO.INSTR.NO. DATE (.'oV3.Yla rei.No. cayv 7v f .i ��nmption, you should become subjecf� to ihe..Workers' �- �E�at - '.npensaiion provisians of the Labor mde,you must�forthwifh i. .oesceianoN �oruo. Hwv.pks7.wioevwc _�mply with soch provisions or ihis permii shall be deemed � —_-- revoked. � � stoa TRACT STATE ENCROACHMEN7 LICENSE�7 CONTRAQORS:DECLARATION: No,oF siocs. °`-Rn°,iT No. _— —_— , SIZE OF LOt NOW ON LOT f hereby offlrm 1ha0!am Gcens=d .de provisions of Cnnpier ` �yt�F —"''-'— - 9(commencing�.vith Section 7000)ef Divis4on 3 of the 8usi � euuo!Ncs y}'$'). i£' -�:�:-Tl CHnkGeS . � ness ond Professions Code,and my license is in fuil forte and ; � � CONNFC1iON CHARGE fEE eftect. +7 t7p !1 mNrancroR�"OII! �,''�'2@712�,Tt CiG3Y18'�'.� � License Number�_t���xO�Lic.r�pss t r'3q• / ADDRE55 ��y�_���e��J�O(j, �'. uHMelJkseMENr FEE �_. COr1lrqCtor 1. 1�Y��EA�SYI Date O/��IF'�O DI>TRICTNO. GROUP .MAP P20Cf5SEDBY Y - t,liY � 1FLN0_ BK P,", �' ❑1 am axempt under Sec._ ' of ihe LA.Co - �i�EN�E NO. SS c ass ,�,.- �� �� - No_ �E�CRff'TIONOP WORK Fee t�.!�. � Plumbing Code and/or Sec. of the -. F!Nu y�- " ao�se s Nea ce�Necrinc ro �� �p � �nrF r VALt ATION �, B.&P.Code for ihe fol�owing ranson Puon. Ev ea ���l(�-.�b ,�y. ��, . . i SEP C TANl.SEE..4GE PIT OR �IhAL � . �� . ��1E _ i'�i5 rn�luiJrc��Rk-i��n� / ' _ � ' �. xOJSE SEJJEF CQNM1ECTINC,TO gY g I PRILF Dt�PC5a.5Y$iENi "���� - � '� Signature !co ar r a,o�TiCnn,at�G.oR � � � - QWNEP.�6UiLc�'cR DECIARATiON woaK.o House se�ee �. OVfRFtOW SiEPA6E PII,DRAINFlEN ' I here6y affirm thot I cen exemp'from°he ConLacior's License �. ,Ex-V, SSaDot,oRYevEL4 M?.�;NOtE � - - -� ��. Law far fhe following reason(Secton 703L5,6uisness and Pro . n.rerc,k:rair�ce neANoorv hfouse � c 1 4f/'<`�('. .. `: '::ions Code): sEwte oa�isr�osni svsttnn � ' � - 9'�� �: J I,as owner of ihe prope ty,or my employees with wages as': i �i.-� � � E i iheir sole compensatron,will do the wark ond die structure [ is not interded or offe ed for>ola(Sectlon 704A,8usines> - ��'�,? �- and I'rotessions Code� O�NNER�S P0+'mit S �.� �}"� � � ❑I,as owner of fhe property,am exdusively coniracting wtlh .` AUTHf�RIZATION T�TAL FEE �� �Q -�'E �' � ?�����n-� �(I[Et15E0�COfl11OCtOYS 10 COItSilliCt t�tE PlO�eCi tS¢Ct10T�OA4, '�- �,HAVE AT T415 DATE A CONTRACT WITH THE HERFIN NAMED CONTRA(IOk iU � :���- Businzss and Professions Code). - con�iECT*NE n�ov[��sceia�o cxisrw�owewN�ro me Pueuc sewER u-�,a�:4'``Fj�3 .�x�: CC!�SFRUCTION LENDIN^v AGENCY � �^'' '_► � I hereby affirm inaf fhere is a consiruction lending aqe cy,�� SIGNEDTHIS�DA/�OF " 19�� .' _ for the_performance of the work for which this permit is � owrveaoa l.s�p� � �/�.� : - OWNEFSAGFIk,T�+�s_✓Y1��"�LIF�S:�"io�" issued(Sec.3097,Civ.C.). �— -. acoRess � � � Lender's Name ,; , � ;� Lender's Address ` � -� �-� 1 certify that I hove read ihis application ond stote that fhe?' - � - -a ' � above infotmation is correct.I agree to comply with all Couniy"'_° . -� .ordinances and State laws regola�ing Plumbing and Sewers �r: � . - . - - and hereby authorize_representaiives of this County to enter'< . . - :upon the above-mentioned pYaperty for inspe'ction purposes � . � �� - �"����.�.e,�v k—�S—9"� �; : ' , Signatureo aermittee Da!e ;'_ SEEREVfRSE-FOR�EXPLANA70RVLAtiGUAGE - � ���- �.- � � .-:. - ''� .. --..._ __ , _._. .._ � Z _..._ o N� ..r� Z;�z � ...� y�N m� �w pAp� z ._ . m DCi $ Z.C? .. °� Z�'G14 Q �� '�"� � `� . -rv Z m� r oZ O`Y' '^ ..�� �r-�JZ,ov �n�r3� ,`�:, � ..._._ Tnu> Zn�in? � �:n =�; � � ... 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