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' S. C �,a:., �z� �. .:X S'k�.A:- � 3 .s .3 *i� , :' .: ;: f ' �� � ' . ..,.� I . "+NORKER$ COAAPENSATfON DECLAI2ATION ' ,. � . s � K �� 92 0002 DPW 3 B7, ��,. . . ���-ins�re,or�fi cenificare qf Workers.0���en'so�i eonsent to sel� "' '"' '`"""' ""�' 'P�� � - � � I hereby off Cm fhot� 11av�o cerL cnfe,o ,,,,.,,,,,,�,Fr �bqea2o ., . .', „. _.._, P �Of1I155UYa1TCe D� . CEBOB Y . . �. �... . . a certfied� y fltereo (Sec 3,�00,Lqb C�)�- . �. . . , . ..�. ���L�C��'���Y�'�R��P�.RMIT# s - ,. . ..5 Pol cy�I_ Company s � �: ' ,.. �� .. �- ,. � ..� - � '� SEWE�t ..S�WAGE DI�P�SAL�� �` . ..... . _�;.. �r.. . ;�Cenif ed copy is hereby fu ishe � � "� � ,�� "�'"�' "� ��� "� COUI�TY OF, US ANGE ES gUILDING ANp 5AFETY .�Certif ed copy is filed w the c umy bJildi ig��p �. "on `. .; � �,�.-� �-- ^�.-.^»�'v-� �af�"�c�"-�rw"" .-.'�+' "tas."': �'^-'-..`.'".'.. depart em. : �. . . .. . �� Da etj�����AppF c nt 4 FQR APP�ICANT TO ..1,�L�N � � r",1 1 GONNECTION DATA .. �__�..... C,ER FICA E qp EXgMPTtON FROM WORKER . euaoir� , sint�0µ �� oE�*H �" ., " C'CS�I�`S'it`T'���l�l'"�SD�'Ai`�C� ' no�RE55. _. � � . , . „„�,k„„.,,,� � ' ..a� �R'.fi ,�t. .. t ...� .. . � '� ' t+ `.x : R . r.. ,_ ' -CThis sect�qn n�@d not be completed if fhe Wofk n olveasoy ihe � NHOIE REFERENC� � mo�. �E R �., IOCAI T�Y � � ���pe?m�t s for one hundrec�dqllars^,{$100)or less) - � � ��'�•°��- -�'�^'-^"^TM*'•�"'^^"'� ivPEOicQNNECT�qN�' ' � '�'� �N�Tp`F'k'�i:F`a'�""'$�/--� �""� ,'. ,.... .� . , :.., . . . � NEAREST. �. � . "� �; I cer�ify ihat m the.performan¢e of,tke work for ,hich,fhs ,,,, caoSsBr. - -� � - v. . .cuas P �- ML.T071%`� C/ '�"'pb`t'�'i'd is�;isgugd,I sholl not employ anyperson.in.ot�y mirnner, ' . �-.�.. .�. .�-.. -.- .�. . .... , ��.." . . ."."". .... ""'v"�'ni0 - '�. so a's to become su6�ect to rha Wotke s �ompensatio 4a. s owNER. � co innv No, , Y�oeNo A. V 1 m . ". , . �.. . - A .-�� � NWIL ,,... � iRUNKPERMR..IJQ. .�_ ROADPERMITNQ..�� ,��Dafe Appl�cani AooREss�� '�� , .... .,_ �� . . � , . . ' ""� � . " AFFIPAVIi. WPJVER EASEMENT REC6R6 1NS,iR 1�70�.. . DATE-��.: -� Nb'fTC�'TO AP'FLr�;�NT If after,making�this Certi{i„cpxe of _„ rrv-� Tft.:� ��� � � . � z f � �� om L��wi�h�such�rovsibnsor4� s�b�ec�_�to the Wofkers ,,, ,._ �E�q�. . ... -� ��' . . _� - . � � ' � 9 p QFj,Qr code,,��you TUSifpilhW�h . DESCR�PTION �'-OTNO � �� ' HWY ORST WIDENING ,. ., :.,_ , F p y p th s permrt shail be deemed "' ��" �' �°"� '�""� , . ... a.., ". . . . . " e�CCK:` Tencr � ,.�. ',�.. evaked , . . . .. . m ` � , � _<LICEN5�6CONTRACTOR5D�1�ATl�GN ��" " Ntl F s , .� . SinrE ENtrzoacHMENf O �p� , .. _........ , PERMI�NO' .. ,_ ��,,�,,.,.,.,. SIZ�.OF LOT ' ._ NO1v ON l0� `��, ��,��. �/°� �-""�� � i hereby p�firm fhai I.rQm�iWC,ense4�onder prpvismns,q'f�C�iap�er u5E6F�-� ' " ��V�V.�, "�'�'�, - ' � � "9(commenc ng wi)h.$ec�on 70U0)of Dtvtsion 3 of the,,;,.Bus sunoiN�s , ��� �,.�, ' ness 25hd_Profe�s�ns Code and my Gc,ettse is n full fo!„ce and' ���� '- ' :':� ""'�� -- � ��""�""` - .� � , , .y,-F.,., .�-�. " "-^ ' '� CONNECTIbf�(CHAR6E FEE ' "�f{eCt � d . ' CONTRACfOR ._. ....�.�...-...-,.,.wa .+..M*..».�..r.�,.a.wrw�x� ' '� L cense Nu,m6er�-,`A��,/��lic Class f� AooREss _ � .... �'�'� .' ., ., .. .r.�..� �,� � 7- . . . - —«: -w-,�.xt,m�,�A,s�� .ro.� �-�:z � � - � e eo � REIMBURSEMENT F E � �' ' ,^ :^ . . � . : ❑ , . . � , .� ConifOCYDY �afe . CITY ' "., 'TEL NO Y.: PG .Z� .. .� ,� � �- DIST2 CT NO.: GROtI � hL1P' ...�PROC 55 .6V"'..`.91• ' STAT �. , .. . �� , p. . ❑I am exempt unde�Sec of fhe L A Co .icE �NO �. (�`'f Z"i -�� .aSS � :� 1�� y �,�i `� �- B� • .�� Plomb ..�.� '. �"� -:` �.;. �^ . .' � No oESClY1PYlOK7 C3F N7bt£K "KEe "'�^'�-^'.'"g""°•.< �. ... ._ . . �y.. -' ; "ingLo �or Sec. � of tXe . F'"'A� .. ._ ,"; .. . - w»�.� riouse exEac�NE2iiNcro �� �,,.. onre ,���� VALIDATION w $ &P�.'C e for 1 follQw ng reason � . . pueUc,5E��Ek'_: ""` `. ."` . ''.. ��.N` ' ; , .. , ... �. .SEPTCTANK;SEEVAGE iTOR .:.. �.�. '"� . F�N .-•.'_ . . .. +�. �Y.: - � ��PITSANDIORDRAINK1ElD " ' A� � • .; ,.,� �- Date`; ;; .�:_. � HOU5E5EWEg�C�NNECiinGY6'" '"• ;., ._ . eY - . . „ �- : . . PRIVA �ISGOS� SV5Yc'KK ,.... ...._,.. ,*..« .v..,..��.... e_,..,a........� .4 .._.......,....... � •. 5 gnatu e . � . �CONNE�'T ADDI1'ION� �R �' """"" ... . � .��, .....y -� '^ OWNERBUIL6 ,DE4�RRATION '� � -��Woa�eroNous�sewea � a :.4,y�, .OVERFLOW SEEPAGF PIT 6RAINEIE D � q p � � I herefJy of{�rm tha{l�tim e%efnpt frpm 1�ie�ConfY�Ot�ot s pL,rcena$ � eXiN. CESSP�1 DRYwEIL N�A"n�bt� � � f b����`�� � .�, � ...».«�......w�. _....,. n, �reason Secton 7Q37 5,�Buisnesg ari'i�P o- n.h2,aEv.s�p tyBKNooN HWSe „,_ � ,��, LC1WfOft Z�O�IOWI,g �... ` . . .,: �SEWERQR�QISPOSACSYST�Ni .��. . . . - .�..0 � e e 1 O�. „ fess�ions Co e�i �-.:. ..�..:-,,••�• �.x•+«� . .. . . . . . � ; 1-� _, �,.. ...,. . , _.:. .... „ .�., ... , . . � .: , LJ I,as owner of theproperty,tii my ernpbyee5�i th wdges as „._. .__'�_. ,��.,...,,.„„„,�,�,,,„,. � � . � � e a 2 7,��c. ...... . ,; iheir.'sole compensat on w II do the work an�l the stryct�re _,,.�, � � . �� � , �is nof'mtended,q�offered for sale(Sect on 7044 Bu,si,ness, '. ' " -�� � .perinii -� _ S { .�� � � � � �m • G���J��� - � �� .: anil Proies�s ons Code) " `��"�,, .. . , . ' . .�. oW�V�R`$. . . . . , e . . ❑I as owner of the'property am'exclus vefy coniroctmg w�rh ' AOTHOHIZATI�N TOTAL��� �� �. ,�'�L� ��. . � ��Q,G.(�.'g`� . . licer�$ed coniracto s to�onsMu'�Qct the project(5eclion�70A4, �,ipvE Ar TH�s oATE�A CON*RACPw�IrH rF1'E'H E�7F7 NAM 6 G6N�TRaCTo�,?Q � � �- BU511E55anfI�PfO�C551�n5[.O(Je� - � - CONNECTTNE,/180VEDESCRI6E�,EXISYINGdWELL�IJGYOiHEPt19LIL�5�WER� �_ .-^-�..._-.�+:�:. �� 1 hereby��aff rm tha}�there is,a.;4,.onsirucj,i�n� � � �� � �� ,_" L'�ON5'f�U`CffO�t1�LE�NDlNG ffiGEN . .� � �len ng Q�ency �����` SIGNED THIS��DAY OF i,� .�� fo ih;e performance of the,.,wo,rk �r w �ch �� arm�� is owNeaog ;�,_. ' .�-. ,..,.�...�:;....,.._.,.,..w.,..�P oWNERS A,1,`z�Nt �� - ._;,' �ssued:(�ec;3497.Civ C.) � . " . .. . � ADS3kE55 • ..� .� . Lende s Nam,e � . ... „� . _ _... ,. . , , . . , . '�' 'Yen�er s P,ddress � i� � :., ,: , �+w��;s� w ,; i� �� s ,� .. ,..a,. ,: . ...,.< '� 1 ce ' "bat I have read iF��s app�ca�iori and'��41e,t�iat t�ie_ . �r,,, �.,A�.,,��� �� � � .. ""'. _: ...v,_., .;......_.....� ,_.-..,�_. . ,..:.�,_.., ,�-.� -�_ ..... .� ..._.._ �.i` o ve inf rrrlailon,is;iorrect,I agree to camply with allCounty ' ' ' . . '�� ��`. .�.�' .� `..�, . .� .`.� � ' ,=` d�nanc. and SYqte laws„regulating Plum_6�ng and�Sewers, � �� � � �� and her, y authorize represen�al,Yve,s of thj�s,�ountY'to'enter" - , , �,� '` � ._ . . . � . � . �-�� upan th' o6ove.me�fiorie- rty�or inSpeCt on.pu[poses. � , � �- . ��. � , �� � . .,.,�; . . . ��. . . . .. . . .._: .��.�.: .�. �.,�' �. . , , .. � . .� . . . . .. . . .. .�.. . . . . . . !� .. . . . ' �` , Signature,of Permiitee , �;. ,,, �Dofe � �- SEE REVERSE FOR,E2(PLANAiORYLANGUAG�� ,:�r:r ��.��� � -- ����.-� -� � - .,,, , . . . � ...r ,- ' : ' , . , . . . . ' .: F . �. . . �a .. .. :., __ .. � v . - ' = _ . � ,+.. . , ' , �.�. -�-'.`_.s...��. _,� _ . - �,�...._ .t� ., , .,.. . . . . . . .. . . .. . �.. t . . .. .. .. _ . ,I � � .s t5 �' . � ,.`. . �� .u� f F '� �����Q���$�I�w � /p�y���y��x q� �'�{L 49.�� w:i, .,. sa .... �' e ., '� 2 ^cf�. � pp�y+p /c�� /ryyy��p�p,q � A��..� �. . ,�h �rt':� >�;u.,a.'!; w.�a/YCAV1Gbl�Yib1A��YiAW.Ld�lrBsAAtd'9AllJ1M � -... , .a �..i.d ,....,.. .,....._,.. ..._... . - . . _.. ,._.__..,. � ' �PP��V�LS .. DAIE fNSPECTOR'SSIGNKTURE... :.: .�,;..,.:� IA@f@�tl��&�fYSffitP[84'S2II4EX@9M�('SiOdItSHC'�Q'iUT3Yf8Ct�'S.-'. . � NE�ri House sewreR..� .�. , , •,:.�. , ...,. �. � . .�; � . . .:-�License Lww for a6t�folEowzng reasaan(Section 7031:.5;�.� coNniEcrnoorcioNrii ��: � .. . ._. . . : . .'. , .._ . ., .,, .:....:. . .. .. Bssse�ae,ss axd�rufesssn�.ss �odeJ:Any ca�y'ot��osssaty � - � . euilo!a@atwoRx . a.:.:,:, , � . �� ' ,. =�wbuds regueres p<p.eangsa&da cosrsaruct �tser,�.amproare;�. � . � ` anc unrc,seer.Pir,st ... ..,,�..-� . . .:. .„. .. .- . �.y. _�._ .:.deanolfsb;:or rapcaie an,�s3awcluPe..praor R'o,ets..assuaeece, AtJD/ORDRAWFIELO ' ` .. . ` , .�,4P'^C tdl�S E�p ItCt{#t o8'.£ROCj.a p➢'97gP�'-.Sn sd6�-p' .. � c�rooi❑ � oRvwEu❑�: � . -.' : -;. ",. . ': ._y.-�� `��±. . � ...,.sign_ed s4atemenS,tb�'be isfdisevased purswiazes� xbe �. - ,.�,�,...,..« � ALTER:REPAIR.SEwER OR .; - . ' . '..- . - .. . ',�... .... �..,, �... .;t+rovSsiafss of Fbe�oaztTracffOr's Y%canse L.affi FC.ba�per j1�.,. . sewaceoisvosxisrsr�,w "� � .. _.� .. . . � �. ,../cmrxHvraenciseg ruatb Secrlon 70D0)�o.i Dcvusor'a-..3 o,�ahe'�. n � tiiScoNNECY'P[UG"ANr3 " , _. .:.�...� . . `''�`.�' �. .:�.- ...Busc�e¢ru and Aro,f¢ss:oats Cod¢J,�i59�xbat�d+e�s's e:�nmpE. ... ABANDON HOUSE SENIER �' � . . , � {J¢T¢ ONd 9d�PI ' '¢ dZ� ��'• . _ � � . ..�..3 1s" ::d , a basas,for¢ a sged acer.�,�t'soaa.Any-� � 6ac�tFmsevrKrn�K5Q ..-.. � . ... ..-. .u.••; . ,. .,,. . vsolaEio�i�of,Secfaoer703f.Sb�varcyappl4casat}os�u�esvro�R� �ep:rrtls)O �ssroots� .. ,.<�. . - s ,,., . . ... sub1ecas tbe� 8' t- a sevsLpen¢Ltjr af xisx araore slsapE� .. . app acq� so ' ��-' . ,. . }� W z . � ' . a .: fdve�randred dodksrs!ffi5061•: ., .... .�-. �:.�-: � ..., . .,,.�.�. �, , �,� � �.,' � - � �� �;� `� ,. >..a:,,C�I,ac ths ownee of th�propee�y will da ihe mor3r.and'.- . � .... .:. ..." .. _` . . � ` .the aFructsire is nat incended't,br oSfered fon sadp: ' , . ... .. ,• s�. �'��i ,�.,�.;lSec 7P44��Bttsd�aace°�nd 3rsafesssg?as�'ad¢:�Tp'i�Cc>a- .. . . .� ... � �..� � ,.�, ..c.. . ... '�. .,:;� � . ,). Eractor Eice e ' 'r�'ois�aaot apply�2b au`vwne�of:.� . . <.•. .:� 's ws I.au�' � � ,: -. .�.. ._-... :. . . ;� ,- . '� ..: ` .� . , . ..prog7erty aobo baadFrl.s m�sr¢s�rouer;SharsaaF,;ctn�who doss� . � ' . . � � . �.;. .�.....� �'� °` :� ��� � srecds wori�-bssras2r"f,�rr'rsvidetP t&ak�srae7e a`s�sprovements � . ';; .. . . � -.'. ,,:.r.__. .. ;;' �.. . . . .: . : ... - ,,,as¢�oti 4aaissedar,d,vr.offeled for sale Ij boevever,6&s�.. . + .:... .. :.'__. .��° ..:-. .i. .._ :� .;. '_ �. ".`bazildit¢g,,-mr��smprane»a�rsx£.aso7cd.vnsfiexayAe'year'of-. . , . . ... ., . ._.. ___. .- ., .. - .: : �::�cona¢detem», 3iie owv�er=ba�stder ziwzdl bavr E1�e daaxrdsvy,. . � � o,�'pmuiug,t'sat be dfd xsoe Sttfkk::or;�pratie far e�ie'�� ,... .. . . .. . . , , . ... x '"' ..,..3 .., rpar,6ose o,fsrade.,3 � k � � .,,., _:_., , :: _ � . . ,� ,_ Y q, � . ... i� . R 'r " ` - e a� . - . . .. . ,�v :. . - .. ' � i . . :_.. ',: ..- �_.:� ' . �� - � � � L am 8�emfYB�II�e�5@C �� - � -� � S.:_... _ . _.c; . , i - ..': �:. _ _ : . _. - -. : �&P.�.�or tlass reasonr < - , ' .� w,,___:,x.�,.��.�u�..�.4�„ �.:�..� .�� ..�_. , _ . ,.. , _;; .. ,�. . ....:, . _ .. _ . _ . , z ..,,�,.�. .,_._...�,� �.r_�.�...,..�:.�.�� n ,�.W w �.: ,. ..�...�,� : - . ' Date ':_ . . ; -. _... � , � : �. �� ��. .. _�,_, .,.- — � .M,.�.v_ .. �_��,:-� � , .; . ;. w. , : , ZS�vmm . : . , ' ,�„o-.�,�.,,� � �. 1 .. , ,�� ' ° .. ..::r�...,�. ._-_ __ . .. 7.�,.��» � ,. :_ �.�.��:;.._ . _ _ ? � � 7= �aus�eetoa�s e�oTes ' . . _ , , ,:. . ..+ _.w.. . . ��.,° . . _r.�., ..»� _ ,.< - . : •, , _� ; a , ��_ .. . �� _ , . ,_. � , .,-„�. �.,,:_. _ � , _. � ,�. .; � y ,.. _.. �' . � � � „_ , .,_ � ��„�r��:�aa,� _ � . . :� . ., t r ..:�, . ,,„ , ..; . ,, �... _.r. .�, • - . > _ .. �:.�,n� . r . vv�ai^c�:,anar.a;c�r-,w�c;�s.rz'a�s.zrr.-.•-;�^a,�ax»�:..,,�.�,..�..�. .. , . .... ; . . . �. . . .. � .. ..y�.. „au- . 7�ae 3�s�w�vr#a,�,*�ek3mar�+r0 � .. �v.. .._. � .... . � .. ..:, . . . '„ .. x 'r '�,a � N � ; g�,. � . , . _.._-. n.,„e.„ z,�y;yri�+,�a.�a,a�, {=,�t*_rY�.,_ "' . . _ � ,<., v. F "f � � v'"hn k _yw�,,� �-v ..y '" t} L � Y S . ., ��',; � w . . _.' . SiCI tlY b m6iq'fiE�...�� . ' .� , .. ._ ., . f J i � . . . .. . , . . „ .., � . . .. � . . . �n �.i���f,..�.. .., .�� -,:: , • -^ .:.' -.,.,, � . . � . . . . .�. . . .,.�_'. ,. ._.::�.u.... � � . ..'... ..uw.w...:�:........�,.»..:.t'wa m»........u.,..F...'. . . - ...... �.. � �&, .�:� �,"