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1757A
� WORKERS'CCMPENSATION DECLARATION �• / ^ �i I hereby affirm ihni I ha�e o ceni(im�e of conseni to sel( ,� � insu�e,or o ceriilica�e of Wor4eri Compensaiion Insuronte.or 76PF.�YJ � a cart�fied cepy thereof(Sec.3800,Lab C.J , ����°F�-�A�91� APPLICATION FOR PERMIT � Policy No. Compony � �?� ❑ce��.+�ed copy;s h��ebv r�.�,.hed. SEWER - SEWAGE DISPOSAL ��n�ied copy�z f��ed�..++h itie to�nty 6uilding inspecuon COUNTV OF LOS ANGELES BUIIDING AND SAFETV deparimenl. Oore Applicn�� FOR APPLICANT TO FILL IN �f�'j;/-L GONNECTION DATA CERTIFICATE OF EXEMFTION FROM WORKERS' nuro:no 1 � 5rar•oN �' ,.r ����!''SfvrH COMGENSATION INSURANCE �^.oQFss O � U r �0 �`!�?" f J (This seu�on need noi 6e rompie�ed if rhe wnrk involved by�hr. � AWkHqE REFEqiNCE ! � � . permit is for one hund�ed dollars�5100)or less.) inc�urv �„ d�J�� S t R ran�sr rrrto�caxh:riati •.[�+c�ysaa+ 1 cer�i(y ihoi in��+e peiformance of�he work for whkb ihis cxsssr. � v, turte P� M�.TOP.�. r pe�mil is isSUBd,�shnll not employ ony person fn any monner p�� U`�E13 Q so as b becorie sul�jec�+o the Workers'Compenw�ion laws. r.w�c T O[ r �t x [o.•���r+0. ioa No � V �pl! Applico�� n^w'QF55 �('�/��. rj,�� } f� [ f4UtiK PE9N:i NO 40A'J PERMIL NO � . NOTICE TO APPLICANT: li, of!or r�ekin �Fis Certifim�e of y a�r:onv:t w:.,v[a E.sivtvr arco+u.�+�s•H w en4 �� 9 o*r � r ru.r+0 /f 7 �) - E�emp���n, yc� should become su6ject to �he WorAers' iF� 6 ❑� � Compenwrion provisions of�he Lnbar code,you musi fo�•hwi�h oexo�vrava ic*NO � p Hw�y.pe sT.w:cFv�w �- comply wirh such provisions er itiis ermii shall be deemed �� P fBVOkEd. &OCK iRF'.f � � 5'AiElV^.YOnCw�NI � LICENSFD CONTRACiORS DECtAAATION vo.cy�u�s �eMn uo I hereby o9'vm�ha�I om licensed under provisions of Chap�e� v7[e•ior �Q�' ww a+io� . ux a 9(commencing wi�h$eciion 7000)01 Diviaion 3 0!�he Busi• y,;r,ou.;c5 � h • + Mf' V hf J �npc.�s � nes:ond Proless+ons Code,ond my I�cense is in full force ond � C Y�S COwtiFCTON CHaf+:.E FFf e1fx�. � c%vvre.aea /� d � UcenseN��rber LicC�ass �ffu gy uI, RHMBUpSEMEWIF[E � Comroclor po�e 7�_ t75 ae'a•cT w �ec�r wr aooccsseo sr C:!Y iEl�.O I / 5'�1E r �'C � � � 7�1 /w ❑I am e.empi u.^.der Sec. of the L.A.Co. t�cEuu r�a. 7 'J Ra55 � � �� �-' ���� � ��.!!���� � r.O UESCk�VII(XJp�WVRK �fE � Pl�mbing Code ard�cr Sec. of ihe H�� rw��s�se.�a carxm�::.ro �/J �'''c � ^��.�y'— VALI TION � B.8 P.Code for rbe follow�nq reason nux�c se+re Sf 'YR 5[EP�C�E a�O4 Nhl.l F"S rNO�CR�R.o�K�Et:1 DotB tOuSE SENEi COnNECT��.G 7� BY l. W YA�f�� Y N ,/•'��(�•�� S�qnoNre COWhfC1 4]Dt�pn���yp(.qt � < ' QWUER�6UILDER DECIARATION �`"'°K�����"u'�F" � Q.¢R�;pW Af.E Pt,�jpa�NiKL7 I herehy eNirm thoi I a�n exeMpl(rc^i!he CaM•at}c�3 License , v.CESSPOOi.Dprv,?���.MAh.+plf low for�he foilowin9 reason(SeUon 7031.5,Buisness o�d Pro- a��ra.ero,:a aa.a.w!w NC:�� :'� ;%�'?^, IIltii0�5 COdl�: Sf WF4 M.'.�S�SaI'.v5'F M. I ❑I.os owner oi the property,or my nmployees wifh wofles a6 � � � � � t � the�r so�e compenw��on,will do!he wo•4 o�d the structure is no�in'ended or oFfered fa sale(Section 7Ddd,Business � • •�1.:)0 � nnd Prolassions Code). OWNER�S P9rmit S �B f�f ;�ur � ❑I,os ewner oF Ihe p�ope��y,am r*t�usive�y cc�'�oding wirh AUTHOBIZATION 10TA1 FEE � ' ' `� '•" . licensed conlroc�o�s ro cons��uct ttie prolA��(�«ion]ad�� �HAy'F AT THS DA'E a C�1�GP{�WIT�1�M Ff4i'il N4y(7 CJN A�1'�`�^1� Businest ancl Professions Code). CO^+^�c7 7r+t nxOv[oesccyee�exismNe o+rtn�r:c;ro rNc v�x�c s�wFe u,4 U Q—Q� CONSTRUCTION LENDING AGENCY •Ai- c__.� G� � tiereby aHirm �hot 7Fere is a consfruciion lending agency ���+^�ED TM•5 D ��NZ� ► � !or �be rfonncnce cf rhe wc�k for wh�ch �his erm�� is tr''��� Pa P O�'+F.S nGFvi ixsued�Se[.3097,Civ.C.). � ' ADORF55 Lender's N�me lender's Address 1 certify�ho�i hnve reod thls opplko�ion and :'oie�ha1 Ihe o6ove iniorma!ion is correc�.1 ogree to comply wi�h oll Couniy ordinonces and S'o!e laws regula�ing Plumbing ond Sewe�s, o�d hare6y au�horire reproseniotives of fhis Coun�y to enter on obove•men�ioned properry fcr inspeUion purposes. �tir/'1 � .�A� 9-�-e3 Signol�r }Permillae Pote SEEREVERSEFONEXPIANATORVIANGUAGE _" ^ '41��� : �' SS i'', �`, c•(�c:��' 'U ��; 3•t� T.r: f� n. �i� �' v' r 7�� :;r G �7' : V J �>. (1? 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