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WORKERS'COMPENSATION DECIARATION , � I heroby off'vm Iha1 � have a certificote of conseN ta self - _ � _ _ _ . insure, �a cerfificale of Workeri Compenwiion�nsurance,or ��`��D - � � o�a, ed copy�hereoi(See.3800,lob C.) �E��R�.e,e„ APPLICATION FOR PERMIT Pol'y No. Company � � �s � Certified copy is hereby(urnished. SEWER - SEWAGE DISPOSAL ❑Cerrtfied copy is filed with the mvnty buildtng insped�on COUNTY Of LOS ANGELES r BUILDING AND SAPETY � , deportment. � � - Da�e Applimnt FOR APPUCANT TO FILL IN - �� , CONNERION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' euuo�ric��/�/ 5- GE��N� E, /� /p � COMPENSATION INSURANCE noo�u 'y'G/�/p� ✓ sTATion� � o[mH � / . (ihis eection need nor be complered if iha work involved by the i�iiTr (/y/�/(AvUT - MIANNOIF RFFERENCE S�f"�" a permil is for one hundred dollors(E100�or Iess.� ' ��St �/ . 7ypE pf�pNllE�liqa . IEN�TH fROM ' I certify rhat in the performaace of the work for which�his ccoss sr. ����i'�'{� �'��i//�fr y, NRg p�, M.L TO V.l. � . permit ia iss�ed,I sholl not employ eny person in a�y manner �T P�� q d so as to betome subjeU�o the Workers'Compenwtion Lows. p�Fq-'r/��L�YQF �Q �'�iCq//� [o,irnv.No. � � �oa r+o. �a{ � ; . AV11t `y�,�X Z��y� iRUNK PECMI7 Np. IIpAD PERMIT NO. ' � - Da�e Applicont AD°�ss [� �zQr �I.' AfFIDAVIT wAIVFR EASFMENi RECORO.INSTR.NO. DATE O NOTICE TO APVLICANT: If, aNer making this Certificote of nry�i�'f�(/�j %.C� tEi.bq. /l� S�—Q,�7 V ' �nplion, you sho�ld become subject fo the Workers' J� �, �Rpensmioo provisions of�be Lobor code,you must forthwith� pEy���p.�� lOT NO. T Z ' NWT,pR ST.WlppNiNG ' � . comply with such provisions w rhis permit sholl be deemed 6�p�� ' � H revoked. � 6iocc � iaacr 7 SiATE ENCROACHMEM , F'� � LICENSED CONTRACTORS DKLARATION r.q.a azous. • , �FRMIT Np_ � � . I hxeby offirm thot I�am licensed under provisions of Chapter siz¢orior riowa�iot �L� • n�I z� , 9 commencin wi�h Setlian 7000 of Division 3 of the Busi- �� il/�/t/ S/N�G!-E,SQ�YJiGV GY V ( g ) eunaracs /�� a s ness and�Professions Code,and my license is in full force and ��NN ��/y/� J� � � effect. �/ (� Q [orarRnaat (,�sily V LR�• CONNECTION CHARC£fEE License Number'� �+✓��jC.C�OSS G�//�✓ qppRE55 BZ�t� /1F4I�i� �.IY REIN.9URSEMFNT FEE ' �OfNfOCiOf�LX'�N� �O�@ er/� C7�J' �.' �0�� 6 '!¢7 DISIYI[T NO. P MAP PGOCE$$fp BY, piY TEI.NO. 7 J J ❑I om erem t under Set. �of the LA.Co. ST°'rE .90¢�853 u�' � 3 ��/�/ .. P ueeNSE na. aas��'/ PI�mbingCodeand/orSec. ofthe �� DESCRIVfIONOFWORK �e FINAL . 'aus�s�uveR cow�an�c To � on.���5/�3 VALI ATION (((�����, ' PUHIC SFWER �., - B.g P.COdC�Of�FIB IOIIOwi119 10050❑� SpVf��7ANK,SEEVNGE PI7 OR �A� . � ' �TS AND/OR DRdWFIELD Doie �+ous�s�wu+coraNeair+c ro _ °Y /�— :'1,1 �.1 A ' PRIVATE ISPOSM SV i � . � n SI Jl101ul6 - � � CONNFCT ADDIiIONAL&DG.OR � 'f?• • .� . � OWNER-BUILDER DECLARATION ���o r�ous�s�wea . OVFRFIOW SEEPAGE%7.�RAINf�EtD �r-e.�C'7.'n . I hereby affirm tha�I am exempt from the CoMractor's Licanse � [xrN.,cessvoa.oavweu.n�wNae �i Law for�he following reoson(Secton 7031.5,Boisness ond Pro- uha.a[vaia ce nenNoaa�quse � � � � � \f•ona Code): sewec oa oisaos�t 5v5r�M . • +�•�!J n� I ,_f i �.�,...;e.�{ttie r.�pe.�.;,c...,y e..,��oys�.with:vages cs 0�� b—F?.; Ihair sole compensotion,will do the work ond the s�rocture � , �- is not in�ended or offered for wle(SeUion 7044,Business permit s � !7 � ond P�olessions CodeJ. OWNER'S . ❑I,as owner of�he properry,om e.clusively tomrac�ing wi�h AUTHORIZATION TOTAL FEE �7 � . . licensed contradon to conshuU the p.ojaU(Section 7041� �HAVE A1 THIS OAiE A COMRAC7 WITH THE MREIN NAMED CONfRACiOR�O BUSine55 onc)PlOf9S5iOn6 CO[�e�. CONNER THE ABOVF OESCRiBFD FxiSTING DKEIIING TO iHE PU9LIC SEwF4. � ' - - -- - ; - CONSTRUCTION LENOING AGENCY �6Tf'/ A��tr" � ► I hereby affirm fhat Ihere is a constrottion lending ogenty SIGNEDTHIS AYOF '' 1 � - for the performance of Ihe wo�k (or which this permil is dPi�R . � . ' issoed(Sec.3097,Civ.C.). � . °wNEQ , . , aoo�ss 2� � Lender's Name . Lender's Addross �R���y��� �'�• . � . I cerlify that 1 have read this applimfion and slale thaf the � ' � . above information is corrett.I agree fo comply with all County � � � - ordinances ond Sfate laws reguloting Plombing and Sewers, � � � -� � �ond hereby ovth ize reprasenro�ivea of�his County to enter � , . � .. ' � upon the �ov - n�ion d property for inspection purposes. . � : .. . . . . .. � —�6—eY3. • ' $" afu�e Permitlee����Dtp.,�S`� � SEE REVERSE FOR EXPLANATORV LANGUAGE � CLyN 1 ' ! ' , ' , � .� � � � � . . � . � - .. . � ' , e��� N� � m / . .. 1. .. , , . Y � 7Q �� � �� c� � ' , . _ _ : A� �„z, m v $ n ri v1 F � ao �y z'^ bt � � _ _ � r ' • ' . .. � /�� � C�rZ� v�i.'� ❑ D�� AOV M D . N ' ' . �i D n'� An� z'�' �v m "CJ , ' T ' . � , , .. ,S^,�N 17 <F :�';o �O S � . O ' � � . Z� A p NO� A O O �C^ � O H� �A � � ' O • - . � . . � � � � , � . h � . . . . ' . . ' . � ' ., t . � . i� - . ' . D .. _ . .`� \ ,.. � � ' � • "- � � . � N � � ' � � � .If� , ' A I . � I � � � ' ' . N N I ; z ' ,f ' ` r% \ � _ �:: ti, . � ��: '� , � .. .:� . . . . ; , ' _ ' . . . . . • . r . . . . , . i f � � � ; � � � , . ! � . . i! ' c .. � � r � � � . ' . . i . . ' . •. .✓ . J ' . . . •� . ;,� ' N � , `` J � • ` � � 0 . " . . y ' _. . � - � ' - ' .. 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