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1766A
WORKERS'COMPENSATION DECIARATION . �� 1 hereby offirm �hol I hove a te�tificote of to�sent to salf � �� _ . � � . , �� � insure,or a�certificate of Worke�s'Compenmtion Insurance,or �_ �"6'�D � . � � • � � . a certified copy tbereof�Sec.3800,�ab�.> . .. . �E��R�,.B,e„ � . -. qpp�ICATION.FOR PERMIT � � Polity No. Company � Bs � , . . ❑Cenified copy ia heroby furn�shed. -� � SEWER - SEWAGE DISPOSAL �� � � � � � en�Red copy is filed with�he county building��.P��fior, COUNTY OF LOS ANGELES BUILDING AND SAFETY deporlmeM. - � po�e qpprconr FOR APPLICANT TO FILL IN ,��.(J CONNECTION DATA � ' � CERTIfICATE OF EXEMPTION FROM WORKERS' Bunom�. p COMPENSATION INSURANCE - . ��u D � / ♦N �/ ST�tror� d f�7� o�vrH .. � (Thia section need not be completed if the work involved by ihe , ���n, AMNNOI[REFERENCE ' /,�j�/� [_ � °PE � � permit Is for one hundred dollors(SI00)or less.) - - ry R I certif thot in rhe erformon�e of the work for which ihia �'�ST 1 T�v[a�a+r�c'r� �r�THFaon�' , Y P CROSS ST. T Y H Y. NRB V. M.L TO V.L �' � pe�mil ia ixsued,1 aholl not employ ony person in any manne� P�� �s- � so as fo become subjxt�o the Workers'Compe�sotion Lowa, p�.�ER � � � - �_i��.p � ���,q � Q 0 _ - � ' ��� . � � �1'^'t A ., s Zj �UNK PfRMIt NO. ROAO PERMIT NO. � V Date Appliconf . .000eEss � - . '" � . � AFFIOAVIT WAIVER EASEMENT RECORD.INS7It.NO. DA7E O NOTICE TO APpIICANT: If, oHer moking th�s Cerfifica�e of an. y� i[�.r+o �y 7�- ' � � � V ' Ezemption, you should become sobject to the Workers' C � Compensa�ion provisions of the Labor code,you mus(forthwith � oeycv�vrioni �orr+0. p - � � wwr,pR sr.w�oewrtJc 0- � tomply wilh s�ch provisions or ihis parmit shall be deemed �7 y . - revoked. . eiocx TRACT �� / STAiE ENCROAp11yfM � Z UCENSED CONTRACTORS DECIARATION � r''°,o��°cs. r�RMir r�o. — � I hereby affirm thot I om I�censed undar provistoni of Chapter sizeaioT Q�� woworiiot . �a / - 9(tommencing with Section 7000)of Pivision 3 of the BUfI• �IIDINGS O �( s, ae�ec�5 ness and Professions Code,and my license is in full force aod . . . � BHECt.- ' . � �pNTRACfOQ �'�.y� � CONNECTiON CNANGE ffE '. License Number Lic.Class - �Eu MBURSEMENT fEE ' CorHractor poie - � RKT NO. GRWP . 'NAP P40CESSED 8V ��,� ., ,. � ,E�. . ir � � �� � � � ❑I am exempf under Sec. of the L.A.Co. i��r.�p. � 'anss �� '� ��JL7� � Vlumbing Code and/or Set. of fhe � �� ����T���WORK r� HNqi � - , `ause stwec conir.�cnnc ro oa� Q VALI TION �B.8 P.Code for fhe following reason � �����R ��—' v.j . SERIC TlWK.SEEPAGE Mi OR ' � VITS AND/OR DIIAINF��D �A� ' - . Date . �aus�s�v+[a caar+[criNc ro . eY .�i,.l� (/ - � PRI AiE DI Y M . � � $191�O�Vf@ CONNECT Ap0171QNAl&DG.OR , , OWNER•6UILDER DECLARATION wo�ro i+ouse sewEc . , OVEIIfLOW SEEFAGE%T.DItAINF1�lD . I hereby oHirm that�am exempt from�he Conuac�or's Licensa � � exrN.,cessrooi.oxrw[u,Mnw+oie . . Law for the following reason(Sedon 7031.5,Buisness and Vro- xtea,wFvnia at aenNooru House . �-- - - � 7 Q 6 a fessio�s CodeJ: � s�w�R or�oisvosu 5rsteM . , �. ❑I,ae owner of Ihe property,or my employees with wages as �• • ♦�• � � their sole compenwrion,will do the work and the slroclore . � � � � is not intended w offered for wle(Section 7044,Buziness � - � -� �- - '�'. .2 7 r.��o ; and Professionz CodeJ. OWNER'S Permi� f � ' � ��,os owner of the property,om exclusively cororatting with AUTHORIZATION TOTAL FEE "� • • •z'J,5 Q� . Iicensed mnlroctors to consiruU the projett(Section 7044� �NAV[AT TMI$DqTE A CON/RI,�T WIM THF NERFIN NAME�CONiNAC10R f0 � Businau ond vrofeu�ons Code). cow�a Tr�neovE ce�o exisnr�owewNe To rr�weue s�weR. 0�Q O G—O 2 CONSTRUCTION LENDING AGENCY � � �+'� ► � iereby offirm that there is a construction landing agency SIGNEDTHIS� � OF 'p � ro¢� . ��� - � - � ��� the erformonce of the work for which this ermit is °W"'ERat _ , �ed(Sec.3097,Civ.C.)..� P . owr+eas nc,�N� .. A . � . . _., . � �er's Nome . � � ��Ess��r� �jt� �^' JS�� - � br's Addrasa � - � � � iify tlwt I hove road this applica(ion ond stafe thot the . . � � � � - � . . � e information is mrrect.I agree to comply with all Counry . � . . . �� ances and State laws reguloting Plombing and Sewers, ; � � � � ' � -- ie�eby authorize represeNatives of�his County to ente� � � � ' � the above-meMi ed property for inspettion pvrposas. � � � �,"` ��- %-6- �� �oture of Perminee Date SEE REVERSE FOR ERPLANATORY LANGUAGE ' , . � . y �cS2 `�f mg .� o� 02 �o i c 3' 'F��� Q� v'.�° � �n$ �'r '" ,�q ` ����m a q d�°o `�4 :9 � , i� zQ '�?o p �.v �°y �" UG . � � �'c+�CG �4 0 ��F� f , � �� � � ' � � � ������ �p � � � - . • , �b�'' �. � . � � 0 1 `� o � a . A � T R 'a � '. . _. . ' C� n . . ,�v . � ' ' , � �. . {!� ' �p -0 . N . ((A� . . , . ' `� . -' 1P . i1 . Z i " . St1 .. - . . . ' . • . . . � . . . � . . ',, � . . � ... . � ' _ , ' . . ` _ , , . , �; - �.`� - . . �` . t! , . ), . . ` 1 ' �.. 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