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1770A (10)
WORKERS'COMPENSATION DECLARATION . _ . � � I hereby offirm rhor I Fwve o cerlificale of consent-to self _ . , . � . �- inaure,or o certificote of Workers'Compensotion Insurance,or ��`61�0 � . ' � . � a cerlified topy theroof(Set.3800,�ab�, �E���.e,B,> . � APPLICATION� FOR PERMIT - � �� � � Policy No. Company ' �� . - . � ��Certified copy is hereby fomished. SEWER - SEWAGE DISPOSAL � � L�1 Certified copy i:filed with�he munty buflding inspec�ian COUNTY OF LOS ANGELES BUILDING AND SAFETY deparlmenl. oo�e nvPirmnr POR APPUCANT TO flll IN � ��j(�•.S OCONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' • euuoirvc. ' COMPENSATION INSURANCE �wort�ss � Ll � �I STATior+ � �mN (Tbis settion need not be completed if the work fnvolved by the i��t� ��0 Y. M4NHOLE REFERFNCE �R permit ia for one hundred doliors(E100)or Iass.J : T�v�octor+r�tTiar.� I certify ihot in rhe performonce of the work for which rhis c�ao�ssssr. 1� r� d r. . cues vl.� M.i�ioP.� � � permit is issved,I shall not employ any person in any manner � � P.�,NO. O so os�o become subject lo the Workers'Compensotion Laws. p�Ep � rQG � � � �p,�µp,pp, �pg Np, u _ ��� F TRUNK iEkMIT NO. ROAD PERMIT NO. x . Dote Applicam - � . Aooa[u b 'Pr �� k , NOTICE TO APVIICANi: If, oNer making this Certifitate of ��TY � �i� ` '� ''7 Q -MFFIDAVIT WAIVER EASEh1ENT RECORD.INSTR.NO. DAfE Q E.amption,, you should become subjetl.to the Workers' r w . LEGAL Compensotion provisions of the Lobor code,you must forthwi�h DEKRiPfION LOTNO. � � HWY.ORST.WIDENING _ ' � . mmply with such provisions or this permit shall be deemed -- ^ � revoked. � � � � . BtocK TRACT /C .�� STAiEENCiOACHMEM � LICENSED CONTRACTORS DECLARATION � � � "'°.a&°�5. �w.�ii r�o. � . I hareby aifirm that I am licensed under provisions of Chopter ����T Q Q �ow o�.�ioT � � 9(commencing with Section 700D)of Division 3 of ihe Busi- Wuwr�GS tJ h � � t7a¢c�s nns ond Professions Code,and my license is in full force and . � ' � effect. � � - � � � tOwiWiCTOR �.� CONNFCiiON CN�RC"#FEE � , litense Num6ar Lia Clau � p��ss �'� REIMBURSFMEM HE � COnt(OC10( ��� CITY '+t� d(�,. �. .��� . DISTRICE NO. MAP PROCESSEO BY ❑I om ezempt under Sec. - of�he L.A.Co. i��r.p,� n,yu — .� � �`�� �� � C� Plumbing Code and/or Sat. of the NO� SCRiPTION OF WORK r� FiNAi � . � ����R coNr.�crinc ro n DATE �Z�r�� VALID ION B.8 P.Code for ihe following reason �� � SEPTiC TANK.SEEPAGE PI7 OR . � - � P�75 AND/OR ORAINf1ElD FMAL _ � �IB - WUSE SEwER COMIFRING TO . BY .j� �. . ,. - ' PRIYA7 D1 SvSTEM � Signofure . � Cav�cr noomaut e�oc.oa � � OWNER-BUIIDERDECIARATION � woRK*o�ou5e5ewEe . - OVERFIOW SFEPACaE Fl7,ORAINFIEL� ' ' � I hereby affirm that I om eaempt hom the Cont.otlor's licenae emN..cessc�a.ocrwEtt.�w�a[ . � , law for fhe following reoson(Secton 7031.5,Buisness and Pro- xhc.2ev�ia oc�ennioor+Hous� � � fessions Code�: � � - - s�vrta at oisrosai svshM . _ . ❑1,os owner of the properry,or my employees with wages as � �'4� �7'�A their sole tompenwtion,will do the work and ihe strutture � � . #• • • • � p � i:not intended or offerad for sale(Section 7044,Bosiness � � and Professions Code). OWNER'S Permit L �J U � •'�2 7 5� ❑1,os owner o(the propery,am exclusively contracting with AUTHORIZATION TOTAL fEE 0 . IICBI15Bd CO�IfOC10f5 f0 COf15�NC1 tI1B PfO�BCI(S2C110f1 7044, ' I HA�F A�iH15 DATE A CONTRACT WITH THE MEREIN NAN£D CONTRACfOR TO . .��a �2�7.5 0 s Busineas and Professions Cade). co�tr T�neove cescaieeo ezisnn�owFxun�To rNc vua�ic s�+rtc. � � CONSTRUCTION LENDING AGENCY � - �',P 19C2 , " �O�Q O O—O Z ' I heraby offirm fhof fhere is a construUion lending agency ' SIGNEDTHIS AYOF � U � ' . for fhe performance of the work for which this permit is �ERs�r,�r�n � issVed(SeC.3097.CiV.C.). A��� . , . . . Lender's Name � - . � . . lender's Address - - � � � - ' ��, I cerlify Ihot I hove reod fhis opplitation and stote lhot 1he. � � - , � - � � � . � - � � � � 1 above informalion is correct I agree ro comply wirh all Counry ' � � - . � � . � ordinonces and Stote laws regulating Plumbing and Sewers, _ � � - - � � - � �� ond he�eby outhorize representofives of this Counly to antar . - . � '� ' u �he obove•mentfon d properry for inspection porposes. � � . . � . 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