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0687A (4)
WORKERS'COMPENSATION DECLARATION . C� I iiereby offiinn fhot I hove a certificme of mnsenl to self �'��DPW 3/8� � insure,or o certifico�e of Workeri Compansotion Insuronce,or �ane�zo:. a tertified copy�hereof(Sea 3800,1����..�� � �EB°� -� - . �- APPUCATION FOR PERMIT P�����o c�m`��Y �` SEWER - SEWAGE DISPOSAL ❑Certi ied c�reby furnisbed. . - - ❑Cer�ified copy is fi�with the couMy building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY de rlment. ,�j����. � ome�ApplimM �'.`,���„ fOR APPLICANT TO Flll IN CONNECTION DATA i � CERTIFICATE OF EXEMPTION FROM WORKERS'. -�� euno�r+c f�! � � COMPENSATION INSURANCE nooa[55 Wt ST.4TION DFPTH � (This section need nol be compietad if the work involved by fhe � nuNr+a[acreaer�ce � ��R I permil is for one hundred dolbn(SI00)or lass.) . 1OVi11TY �� - �owtR PFAREST TYPEOFCONNEC71ON �fJ(�TNFItOM � I cer�ify that in the performance of rhe work for which this � �aosssr. �}- Y. . ��qa p,�, N�,LTpP.L, �' permif is issued,I sholl not employ ony person in ony monner �/� }�,\ v.c.No. n /' � eo os�o bacome subjett to the Wor4e�s'Compensation Laws. � owNea �'-i(� �V V CO.IMG.NO. lOB NO. - -v (� ' M411 � iRUNK PERMIT NO. ROAD GERMIT N0. Date Applitant . � °D°�u � - ; 1$1 /�r pfFiDAVIi WAIVER FASEMENi RECOWD.INSTR.NO. W7F NOTICE TO APPLICANT: If, oNe� moking thia Certificate of �iTy �� �i,r,�p. c�� E�emp�ion, you should becoma su6ject to the Workers' i�Ai� � pensolion provisions oi the Lobor code,you musf forthwi�h pEURipTip�a LOTNO. HWV.OR ST.WIDENING ply with svch provisions w this permit sholl be deemed � .ievoked. �ocK iRRCi SiAiECNCRpA[MMENi � UCENSED CONTRACTORS DECIARATiON - � � � � r�o.oF�o�s. reaMrt nw. �� I hereby offitm Ifrot�am licensad unde�provisions of Chapter si2[oFtOi ,nww orr�or 9 commencin with SeOion 7000 of Division 3 of the Busi- �°F - �� ( g ) euimu+cs �� anac�s ness ond Profeasiona Code,o�d my license is i�full force and @HECI. �' COr1TRPCfOR ` � COnNdERION CHARGE FEE license Number�{��r0_10 lia Class '� A�u � REIh18lIR5EM1AENT FEE � , �Of1�fOC�Of l� C]"1 �,. Pme qlllDrEi.r�w.` ( ..,5 -�C�g DISTRICT NO. GROUP MAV PRQCESSED BY („) ' CITV BK PG Z ❑I om exem t�nder Sec. o the L.A. o. �''°� ���' !� � P LICFNSE NO. GLASS NO- - DES[RIPTION OF WORK FfE ~ � PlumbingCodeand/or5ec. oflhe � v:Nni W 9 faus�sn+hR co�r�cr�ric ro onre �` _ VALIDATION � N%�C SEWER B.B P.Code for Ihe followin fB05011 `� $(PfIC IANK.SEEPPGE PIT OR iINPI Z GIfS ANO/Ok DPAINFIE�D D01@ . . 1pUSE SFWFR CONNFCTING i0 .. BY . S PItIVATE DISPOSAL SVSTEM -Slgnalure ��y• CONNFCl AOOIiIONAI&DG.OR � - . OWNER-BUILDER DECLARATION � �K ia'aus�s�wEa - - I hereby offirm that I om exempl from�he Controctor's Licenae � �rRiF��E55�vooi,�orsRvwF�Ar+aNMae Law for ihe follawing reoson(Secron 7031.5,Buisness and Pro- urea,aevnia oa aenr�oor+rqus� � �� � � - � - - � '� S�SSIOf15 COlj2�: SEM'ER OR DISDOSAL$YSTEM � � � � � � --_. _ �o6e�n ; ,�I,as owner of the properiy,or my emp�oyees with wages os " - their sole compenwtion,will do the work and the structure . _ . 'rt• • • •.�,n is not intanded or offe�ed for wle(Seclion 704d,Business ond Professions Code�. OWNER�S Permi� S � • •2 7 5� �,as owner of the proparty,am exclusive�y contracting with AUTHORIZATION TOTAL FEE O r IIC�IISCd COf11fOC10f5 f0 COIIS1NCf ff1G PfO�CCI(S![�1OIl 7044, ., �HAVE AT TH�S DA7E A CONiRACT WIiH iHE NEREIN NAMED CONiRAC70R i0 . � � ���'���"� BVSIl1a55 Ofl(I Pf0{GSS�OItS COdC�. CONNECT TME FBO�RIBED Ex15TING pWFLUNG iD THE vUBIIC SEWER. CONSTRUCTION LENDING AGENCY 0 S 0 9-8 8 � I hereby offirm ihat Ihere is a consirucfion lending agenCy � SIGNE�THIS� OAVOF �I9� ► � � � for the performance of the work for which �his permit is °W�a� �� . issued(Sec.3097�CIV.C.�.� OWNERSAGE "v� I - - . . . Lende�i Nome l (1^�C�Y P �I , ADDRE55 �n� ��� .a q t7a Lender's Address �,Q� —1. Y�Q�411—�—. 5'�. 4•a. �. . I certify that 1 have reod thfs appiica ion and stofe that�he C�OD''S'� , above informalion is correct.I a9ree ro compiy with oll County , . � . , _ . . „ � ordinances and Stale lows reguloting Plumbing ond Sewers, . � � � and here6y au�horize represen�a�ives of this County�o enter Vpon 1he above-men�ioned property for inspeciion porposes. � � - - ' �- � - ' ��" - � �-3� _ _ igna e o ermitt afe , SEE REVERSE FOR EXiLANATORY LANGUAGE � �% r � �'�f���p�� �}� °��� � • �`^Pz Z �n 25 '�°�' �� yc^" "DO ". � , sF gx oe nx °yp '�D . . ' .� ', _Y z`� v�Y Q D'�, �v � '� . �, . Y�^� � L , T,v A� P O , , , a� ���� o �J�� c . . ' � ' M Z SC.9 <A P� N r , , •„O�7� �y � V► � R A f� �' � r^ i ❑ '' , � � � o \ m � � � � � _ � in O � .- 5 p , g N � N O �.1 N � , , �.� . ti � ;. - „ � •' �.. : . ' ,,,.,. . , j Jt� , _. t' r � ; N , ._ M _ � � � . ' ' _. � ' , ' . . 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