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1757A (10)
� WORKERS'COMPENSATION DECLARATION � , � ��l O ��'�"—�"�'I NG���r t hereby offi�m fhat I have a certificoie of coasent to self � � insure,or a certilicole of Workera'Compenwtion�ntorance,or �dAdd4D � . �� a««�f� d� y rheraof �.3�,�ob�, CEBOB�REV.I183� qpp��CATION FOR PERMIT . Policy N ��� �Po�Y,S�r��_w��� . . . . . ' ❑Ce�tified copy is haroby fumished. , SEWER - SEWAGE DISPOSAL � ❑Certified copy is f�led winc �ounty lioilding inspection COUNTY OF LOS ANGELES � BWLDING AND SAFETY de rtm t. � Dote 2T �'S qpptican � FOR APPLICANT TO FILL CONNECTION DATA ER IFICATE OF EXEMPTION FROM WORKERS' eundr.K, � COMPENSATION INSURANCE noocess Z� sr�na+ otam (This section nesd no�be<ompleted if tha work imolvad by the � i,y,N�E c[FEqFr+t� . ��p � permit is for one hundred dollors(5100)or Ieu.J ��°ry � R � I ce�tify�hat in�he performonce of the work(or which�his Rpu55T, ` TYPEOFC�^�T1ON � '�"�rH�aa'" . r. cuce P.l. M.l.TD P.l. permi�is isaued,I sholl not employ o�y person in ony manner - p�� . � so as to become su6ject to�he Workeri Compensotion lows. � a,ti,�q �y� S'��..pGL � m.nnv.w0. �oe rao. � nNn �j ' Dote Applicant aoorsEu� TRUNK iERMR NO. IlOAO PEFMIT NO. �/J NOTICE TO APPLICANT: If, af�er makin Ihis Certifimte of neviOnviT wnrvER fFSEMENI a¢Coao.w5m.n0. W.TE 9 aTv U'r �ci.No. E.emp�ion, yoo should betome subject to the Workers' LEGA� ' . Compensotion provisions of the Lebor tode,you mvst forthwith � oEsccioriora WTNO. MWY.ORSi.WIDENING comply with such provisions or rhis permit sholl be deemed ro.oked. � aiooc raaa Sf�/f ENCPOACMMfNT UCENSE�CONTRACTORS�ECLARATION ^'°.°°x°�S. ( °E°'N°rp_ I here6y offirm thot I om licensed under provisionz of Chapler siztorioT rooworaior 9 tommencin with$ec�ion 7000 of Division 3 of the Busi- ��°F ( g � BVRDINGS p�ppG(g � �ess ond Pro(essions Cade,ond my license is in full force ond " �'eHlCI. �. .L C0�INECTION CHARGE FEE CM�TR11CT0R K. lice�se N ber���) Lic.Class ��� ��u�Y i �S qeuaguq5�6�r�rt� y Con�roU n1G Dore , /� p ,r q DISiRI�T Np, CaROUP nv,v MOCFSSED BY O CITY TEI.NO.(`� u�`�O V BK PC V � ❑I om e�ampt onder Sac. of the LA.Co. ��Ny�,p���ZL a�SS " � � .-s � NO. DESCRIPTI WORK fEE !�• PlumbingCodeand/or5ec. ofthe F�N�" VALIOATION uVi 11DUSE SENhR CONNECTING TO � '`, D�iE � � trC� . B.6 P.Code for the followinq reoson � 2� 5(p{�C TMIKRSEFPAGE PI7 OR V� FINAI y✓ Z VITS AND/OII OR�INF�LD � ��� HOVSE SEWEN CONNECTING TO 6Y PqIVATE OIS 5'ISiEM Sianalure •�� � . �php�[�t pDD�tiq�ul BtDG.prt , OWNER-BUItDER DECIARATION �K to rausc s[w[a , OVERfLOW EFAGf GIT,04AINiIEID . 1 hereby affirm fhat i am axempt from ihe Coe�mctor's licensa F%7N.,CESSPOOI,ORYWEtI,hUNMOIF Low for�he following reosan(Secton 7031.5,Buisness ond Pro- �urea,cea�ia pa ny,NpoN Hous� . - . fessions Code): � scwEa at msvosu srsreM � , ❑I,ae owner of the property,or my employees wilh wages os �� 7�7 a their sole compenwlion,will do the work ond the s�rocturo � _ is nol intended or offered ior sale(Sedion 7044,8usiness ��,� � �'�� � ond Profess�ons Code). OWNER'S Permit i D .S� , ❑I,as owner of the property,om exdus��ely con�mcting with AUTHORIZATION TOTAL FEE � ''�2�5 0 licensed toMrac�ors to�consirucl the project(Section 7Wd� 1 NAVE AT THtS DAfE A CONTYA�7 WIiN INE HEYEIN N�MED CO ACfOR�O ��'•i = � Businass and Professions Code). CONniECi ni[neovt DtsCaieto ExiSm�ow[uiuG Tp iHE rusiiC 5[wFa. �. 2 7 S O ci CONSTRUCTION 1EN01NG AGENCY , � �I._heraby aHirm thal there is a construclion lending agenty SIGNED TH�S DAY OF - Iq_ O 7 2 9 8 5 for the performonce of fhe work for which Ihis permit ia ' �"kR� � � OWNfRS AGENT issoad(Sec.3097,Civ.C.). noocE55 � Lender i Nome � le ddress cartify th I Fwve read ihis opplica�ion and state that the � • above inform ion is torred.I ogroe to tomply with all Counry � ordinonces a State laws regololing Plombing and Sewers, � � - � and hero oWhorize represemotives of ihis Coonty to enter . � upon v operty for inspecrion urpo»s. � cJ 22 �'� � gnol�reofParminee Oal . 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