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1548A
WORKERS'COMPENSATION DECLARATION � - - � � - - � . . - � i t1erE�'iy at- iiut �G'J6 G ���`������-�`�consent r0 seii � _ � � � insure,or a ceri'ficate ot Workers'Compensation Insurance,or . �tAt�zo . � o.certitied co there f.{Sec 3800,Lqb Cy) - cesaa;uev.eiei; ..__ - -____�y_�H_L���I�hwt _f�yA4.���■.Ey. - Policy No. J¢Cgompany."JT.3 b@ �'Y�11Q rns •_ d'4 �- vl� d.�1C �r� t . -...., ..:.. �Certifie� �'ht'feeY+����5ned. . , . SEONER - �EWA�E D1SP�SAL- � �Certified copy is filed with the wunty huilding inspection � - - � COUNTY OF LOS ANCvEI,ES - -BUILDING AND SAFETY � - � � ' ' department. � . " Date Applicant FOR APPUCANT TO FILL IN COPdNECT10N DATA . CERTIFICATE Of EXEMPTION PROM WORKERS' —�--�� - BUILDING ' $iATION OEPTH � COiv1PENSATION INSURANCf aooaess - �- - Qhis section need not be comple!ed if ihe work involved by ihe . �{�'�p(((�1 nn � �� �� uvveu �, LOCALITV D1:Fi.['SV��D._BliLt_,_ �NHOLERcFERfNC� LOWER ���. � ._permit is for one hundred dolbrs�$100)or less.j . . , NEARE51 �� TYPE OF CONNECTI04 IENGTH FROM �-`I certify that in the�performpnce of ihe work-for-�which this �- c.uosssr. v. Nke F.i. rn.�.1�P.�. permit is issued,I sholl nof employ any.person in ony mpnner �� m�p�y �},�T�},-7—�—r [� � � OWNER 1A.P 13.1.Y.L.k:itY i7�V� P.0 NO. : so as to 6ecome subiect to ihe Workers'Compensation Laws. co.i�rv.Ne. ioe Na ���, .� ��fla19 AppliGattf �� DORESS ,y�Q��TJ�' -�-�2 � --- TRUNK PERMIT NO. ROAD GERMIT ND. � . ��� ! _ � FFFI�AVIP WANER CJ+SEMENT RECORJ.INSTR NO. Dl�TE � ' NOTiCE TO APPLICANT: 7f, after ma4ing this Certificate of . �;Ty (,��V321•a< TEt.No ¢,� - F-emption, you should become subject to !he- Workers' `E�r: tipensalwn provisions of the Labor code,you must forthw ih �.- oesce:ci:oN iarNo. , Hwv.ous.wioevwc ..,,nply witn such provisions or this permit shall be deemed - �fEVOkCd. 610Ck iRA:i STATEENCROACHMENT LICENSED CONTRACTORS DECLARATION "'o.oF giocs. �`RM�?No. SREOFtOT NOW ON tOi � . I hereby af#irm-ihat i.am licensed.undnr.provrsiorts of Chapter '� uyE�f � 9(ccmmencing with Section 7000)of DEv�s on 3 of the Bus � ewtoivGS ������e Resld�nZ''�' cnnrz�es ness and Professions Code,and my I�cense is in full force and.�. . - effect �. conNecnon�cHazcF eFe nr� cfA . C()NTRkC"04-' .. . �__ iicenseNumber �bf�.�t3C5� I.iC.C�d55_r:�L�. M1DpQ�SS ���C "D���hW�Q.7 "[l�r• REIMpURStMENTFEE �'. ', m G7/GWf{JL? h } •1. S� _.__.. 11 SJ , 1.a FTC'��IACZIZ Dofe , ea T�PA �7 q []Q(� q�je�(� DISiRICT NO. GRGVP MAP aROCE55E0 3Y ' COnffOCfOf CI?Yriy 4cM LV�'�'� TEL IrC./��p.,fVV�ry�'Y`J /� BK VG �-. �� ❑I�m exempi under Sec. of the LA.Co p,cENs�H�. � c�55 (!L3 � �-_ �C- ' CESCRIFTION OF WORK rfE ��� °' Plum6ing Code ondJor Sec._ of iha �- -- ��F�Nnt U ''- NCUSE 5'WE2 CONNERING TO 1 f�o DATE ���)i/ �� VRL ATION �, PU9LIC SEW[R V ' $.&P.Code for the fa(lowing reoson 1 ( o �;: � � �$EPT C TAIJN SEFPACF PIT Ok FIfJAL �FiTSPN�O'�D"nAI4�E�C �!�` - �.__ DOIB _ . H'JJSE V�-R CUNVECIING i0 aY -�. $i IIQ1uYQ '"2'i�A E GfSPnS.41.SiSiFN� ` '��� 9 � mUn�c aa:,R��oNai s eG oa , OVJNER-BtJICDfR DECLARATION ��voRK�o HouSE SEweR '�• pvEkFlOVJSEEPAGEPR�RAINFIELD ' ,y�� !hereby alfirm hhot t am exempt from�he Centrodar's L�cense : EXr a �essvooy oerw a nnanHJte � � � ��.�'�L"� r� ' , t lam�for rhe following reason fSecton 7031,5,Buisness and Pio aiTeu,eeoaie oe neanooN�HO�SE�����-� ����� � ' 'sions Code): stwea oa oisPtisai svs�pn ,�,�� � �-� � f ' `y J L qs owner of the property,or my emptoyees with wages as � ' �^ ; 1 iheir sole compensation,will do the work ond 1he str�cture �� � i �..� a£�, is not ir.tended or offered for sale($ection 7044,Busineu and Prafessions Code1. OWNER'S Permit g ,.�. � f �-�:� � a�; ❑I,os owner of the property,am exciusively coniracting with A9JTHORIZ/ATION jOTAL FEE `L � ...: r, ,� ^`�'�I �licensed mnfractors to construct;he ro ect Secrion 7044, �� r%'� -�Y� p � ( I HAVF Ai iHIS DATE A CONTRA�i'WIiH THE HEREIN NAMED CONTkACTOR TO BUSinL'SS and F!o{e55ion5 COde�. � <()1NECi iHt ABOVF OFSCRIRFp FXISiIN6�WELLING i0 THE PUBLIC SEWER. "` CONSTRUCTICIN LENDING AGENCY � s�� '► - '�,�=� f bereby affirm ihat fhere is a cansiruction lending agency 51GNED TH�S—�sT"9/--�OAY O� � 19�� .,� for the performance af the work for whith tFis permit s cwrvea oa ✓�� � - CWNERS AGENT.��/ ;ssoed(Sec.3097,Civ,C.J. � �'��" ADDRESS r � � t:`�� �ender's Name _'__— ;:}.�. Lender's Address _ � � � _�� 1�certi4y ihat I have read�this-application and smte ihat the'�� � � r:��' � .� ��,�:, -.above-information is correcl.I ogree to comply with alI County.:_ : --.. ... .. . .... . . .. .... ;` ---- . . -.. . .. . - - ---- . .. . ;;��, ordinances and Sfate laws regulming:Plumbing�and Sewers,-'�- �� � � -- �y=,���. �and hereby authorize representatives of ihis_Covnry to enter'; - � ;�, upon th above-mentioned property for inspeciion purposes ( � x� �`J��1�_��L�.s g'-�-��''.�-, `:;`� Signature of Rermittee Date � SEE REVERSE FOR EXCLANATORY LANGUAGE - �- - � ^ '."'�,n^�E � . . �� m� .`n^D � D�`,(,' cCi � q x zo n� G' o� a� % � Oz �^r�.! � O"° Zn Q ..',n�z� oD A� �s' K�" � � t� n. �o aA �� �S; m9 Ac z� � y $/�t. o � ." . N R g� �ryA Tp G 1 Rra � � 8� �� �° � `^ � � � � � � n � - � �"� .,�. � o wi n �. rn C � ... .. . .... � .., � � � � �� r�+ � .. _..� . 4'A'-s. � .. �i�. � t �.� � y f N t � Z D y � I m i . . �.� . .... ., ....' t. � - ' 1 C ; j 0 , . 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