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1771A (10)
WORKERS'COMPENSATION DECIARATION - � � � . � , � � I hereby offirm thar I hove a certificole of consanr to self .. - . � . . � inwro,or a certificote of Workeri Compenwtion Insurance,or 70A°°''�D � ' � � � a certified copy thereof(Sec.380t1,�ob�., . =F��R�,.8,8�, � � �� APPUCATION�FOR-PERMIT - � .. � � - Policy No. Company � �� . . . . ❑Ceriified topy ia here6y furnished. . - SEWER • SEWAGE DISPOSAL � �. � � � � [�Erti4ied copy is filed with rhe mu�ty building inspaction COUNTY OF LOS ANGELES BUILDING AND SAPETY- deparlment. Da�e Appltcanr FOR APPLICANT TO FILL IN g ,�5' CONNECTION DATA � CERTIFICAIE OF EXEMPTION FROM WORKERS' eunar+� p suiiow � (7 �PTM � - 1 � � COMVENSATION INSURANCE ' �ooREs` O, Y 4� �/ V (Th�s aetlion need no�6e comple�ed i(the wo.k involved by the i«�un. � i,�,,, O�-, � �n�.r+Ho��crsErxE 3 .S � . permit ia lor one hundred dollo�a(5100)or less.) . n,�pp�q,�i� ��TM�� � I cenify thot in tlie�1Q�Ofman[C O�fhe WOIk fot WhlGh fMiE . �R05555T. Y ��. Y. CURB .L. M.L.i0 P.l. �" permit is iuued,I sholl not employ any person in any manner . P.�.�.p, � g' � ao as to become sobjecf to the Workers'Compenwtion Laws. owr+ER r ♦ a co.�MP.r.a. ,oB�o. G�p � _ �) �.i . . ADDRE55 ✓Y(h�Y' Q f N TRVNK PERMIT N0. ROaD vEWNt N0. 7C �, Date - Applitant Q NOTICE-TO AVPUCANT: If, ofier moking this Certifimte of �iry �i ��� �Frioavrt w�ivca EASFMEM RfCORD.INSTR.NO. DAIE . � V Exemp�ion, you�should 6ecome subject to the Workers' � i n w� � � Compensation provisions of the Labor tode,yoo must forthwith• � o�KRiPtior� iott+o. -�c. � Nwr,02 sr.vnoewwc � N ' -�compfy wtth such provisians or ihis permit sholl be deemed � ^ _ . ' revoked. � . . DtoCK TOACT {- STATE ENCROACW+�EM � . �.�&�5. VERMIT NO. UCENSEO CONTRACTORS DECIARATION� � s�zeator Q roowa+ior . , ' 1 hereby affirm that 1 am licensed�nder provisions of Chapter �� � '.9,(mmmancing with Section 7000)of Division 3 of�he Busi- ewian�s t� f< at�kcEs �. ��ness and Professions Code,ond my litense f:In full fwce and . •e{{lCf. � � - CONTRAROR y� COr1NECT�0�1 CMARGE t4E License Number Li�,C�04S ApppE�S REIMBVRSFMENT FfE �o�,.a«o. �}e < ' z_ ' 0,5,�,R� P MAP M70CESSE�BY . arr TH. � '{ qK �/L ' ]I am e�empf under Sec. � � of the L.A.Co. � I�r�is[wo. /ctnss � ��/ �'���.rJ � , Plumbing Code and/or 5ec. of lbe . ^p� SCRiPTION OF WORK �EE . � pi�i , HOUSESFWFRCONNECfINGTO wTc q VAII ATION .. � 8.6 P.Code for the following reason �&��a -- v /r 2���— . 5[VTIC TANK.SFEiA�GIT OR . . HNAL � ' � DOIB . . PIiSAN�/ORORAiNF�fID g� �^ . HWSf SEWER CONNECfING T0 �// �1 7 7.1 A . PRIYAi 01 � ' $ignalure CONNECTADDITIONAtBLW.OR � ` . wanc ro taus�s�wER � OWNER-BUIIDER DECIARATION p,���o,ti,�EPq��T,deA,NFiEio . - ��• • • • � O � +ro6y offirm�hat I om exempt from the Coatractor's Licanse ezrN.,cessroot,wtvweu.m�rrNa[ � . . . for the following reason(Sedon 7031.5�Bu14nl55 CIId Pf0- KTER.REPA�RORAlANDON HOUSE .. - - - ' '�'• a 2 7.Jr� , - 'OnS COI�E�: � SEWER OR DISPOS/tl SYSiEM _ ',os owner of the propery,or my employees with woges as � •'• •2 7.5�� ! heir sole tompensotion,will do�he work ond rhe structure � . �a O O—O G � � s not intended or offered for wla(Settion 7044,Business � � . � nd Professions Code). OWNER'S Permit S /�Q !7 � as owner of the property,am ezclusively tontroctinq with AUTHORIZATIQN TOTAL FEE I �ensed mntroctors to construct the project(Section 7014� 1 MAVE AT 7HI5 DATF A CONiRA�T wirn rr�HerseiN r�un��cor+ranaae ro , _., _ siness ond Wofessions-Code). co�a n�E�eave ocscai o Exisrw�ovhwric ro T�Puazic sEwec. .- �- �-- CONSTRUCTION LENDING AGENCY � 4�� , � � �y affirm 1ho1 Ihere is a construcfion lending ogency SIGNED THIS- DAY F I9SL�J - � -� � � � � performonce of the work for which thia permit is o�Rs�nG�NT ' . .. . . , ' SeC.3097.Civ.C.J. . � �woef �� �` B � ' . Name Addresa - � . � � tFwt 1 have reod this application and smte that the . . � � .� � � - . _ brmotion is torred.I oqree to comply with all County � � � . " - -�s and Siote lows regulating Plumbing and Sawers, - � ' . � - - � �y avthorize represematives of this Counly to enter �� ' � . � +bove-m tione property for inspection pmposes. -- � � . . . . ��,� � - �� . . . �e of Permittae Da1e � . - - SEE REVERSf FOR EXILANA70RY MNGUAGE . - i F .. . , , - , . � . . , r�g D� �� � gs� �g Z � � ' gn E; � r � - � -' �� ' � , . . , y T pO �" o\n pz f � pZ ��..�o � �-+ 2`� S . ' ' . , . .. . ' ', , . � � . ✓�n Zm o� K '°D Gl� c � � � ' -b� S-� v�o ❑ �•'c 7�ao Y'" Z1 � ' r _, . . . ' r I . ; . �,,n �c� O�, 2SA `z� a' y . l T - . . . . . � .- . '. . � , --� -i m1 ^'GC1 �� �.v �O $ Q . I _ - . _ ' � ; ' N.� �2 K'� A �� �➢ G � ' -- ' ' � ' �o � mo I � . . ' i N p ;p � � �' H N I � � .0 � ; 1 � � . . � ' � . � � . � � • ' . O 1 � 7*j .__ _ . -. . . . � '. . . �(:. ' O ` _� , � � . . ', D . � � �. . � ' �, � ' � , . , . ' N . . . . _. r , .. .� i � . . Z � . � . . . . , . . ,.� . O . r A . , H � . � I .� � . . _ 1 " . C i_y ' ' ,, , , �� i'+ _ )' . . . . 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