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1757A (10)
� WORKERS'CCMPENSATION DECLARATION �• / ^ �i I hereby affirm ihni I ha�e o ceni(im�e of consen� to sel( .� � insu�e,or a cerfifica�e of Wor4eri Compensoiion Insuronte.or 7esn+7J . a cart�fied cepy thereof(Sec.3800,Lob C.J , ����°F°�A�91� APPLICATION FOR PERMIT � Poiicy No. Compony � �?� ❑ce��.+�ed copy�s h��ebv r�.�,.hed. SEWER - SEWAGE DISPOSAL ��n�ied copy�z f��ed w++h itie to�nty 6uilding inspecuon COUNTV OF LOS ANGELES BUIIDING AND SAFETV departmenl. oo�� Applica�� FOR APPLICANT TO FILL IN �f�j�!L GONNECTION DATA CERTIFICATE OF EXEMFTION FROM WORKERS' uui:o:nt; 1 � 5rar�oN �' ,.! �����'�SFPfH COMGENSATION INSURANCE �^.oQFss O � U r �0 ���r' f -1 (This aeu�on need noi 6e mmpie�ed if rhe wnrk involved by ihr. � AWkHqE REFE4iNCE ! �R � . permit is for one hund�ed dollars�5100)or less.) inc�urr �„ ��J�� S t R ra�aFsr rvrFO�cd+tiecrian •.[�+G!yca0µ I certi(y iho� in��+e per{ormance oi t6e work for whlch this cxsssr. � v. turte Pi Mi.roP.i. } permil is issuBd,I shnll not employ ony person in any monner P�� sa as b becnrie sul�jett�o ihe Worke�i Compenw�ion Lawn. r.w�c T O[ r �t x [o.����N'�. JOB MO U��i1.3 Q , / V Dote Applicon� nrA.'uE55 V'r t L. r!,<< M (. � f4UtiK PEqN�i NO 40A�J PERMIL NO � aif:'JAV:1 'A'%.�YCR fASiMEtii aFCO:'U.�':5•R W CaR �� NOTICE TO APPLICANT: li, of!or r�ekinq rhis Certificnie of cin. I r ru.np rJ 7 . E�emp4an, yc� should become so6ject to +he WorAeri iF� �� 6 u� � 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 fBVOk�. &DCK iR<:f � � 5'AiElV^.YOnCw�NI ^ LICENSFD CONTRACiORS DECtARATION vo.cy�u�s �eMn uo I hereby o'firm 1ha1 I om licensed under provisions of Chap�e� 57[c•�oi ���' ww oa�oi . usc a 9(commencing wi�h Seciion 7000)oi Diviaion 3 0!Ihe Busi• y:r,owc5 � h • + Mf" V hf J cl�npc.�s � 1 nes:ond Professrons Code,ond my 12ense is in(ull iorce ond 7 COwtiFCTON CHaR:.E FFf n1fx�. � c%vvre.crea /Z d JnS � UcenseN��rbe� ticC�ass �ffu gy uI• RHMBUpSEMEHtf{E # �OntrO[10r DO�C ��� �` ?�'R'LT M1O "4C'.:f' W� �OCCSSkO 9Y C:!Y iEl�.O J ✓ �/ ❑I am e•empi u^der Sec. of the L.A.Co. SCEt��. 7 'q Rsu — � c�� r-� r�����3 ���%�/�� � r.0 UESCkiVil(XJp�WURK �fE Pl�mbing Code ard�cr Sec. of ihe H�� w��s�senrta cow�cr�::,�o j� �+'e � ���,��— VALt 710N � B.8 P.Code for rbe follow�nq reason vux�c se+re Sf 'YR 5(EP�C�F°��OQ Nhal F'•5 nN0�OR'JR.��I�f�Et;1 DotB tOuSE SENEi COnNE�.��MG i� BY l. aY YA�f�� Y N '•'��(�•�� S�qnurore ca.nfn a7br�o,.u�y,oc;pr � < ' OWUER�6UILDER DECIARATION u;:'°K�o�q��s`uwF" � O'.'FR�iO'/�' Af.Eit,'JNa�NrKL7 I herehy c�firm thoi I am e.ernp�trc^.i=he Can'•ac�cr'3 lianse , v.[£SSrOU.DprwEn.MM.�OIF Low ior the followinq reason(SeUon 7031.5,Buisness a�d Pro- a�7Fa.e�on:q cw�anny�r,p.i Hn_�c. _'� ;7�'?^, IIltii0�5 COdl�: 51 WF4(1R.'.�SMial'.v5'F M. I ❑I.os ov.•ne•oi the property,or my employees w�:h wofles ae � � � � � t � their to4 compenso�io�,will do!he wo�4 o�d rhe s�ructure is no�in'ended w oFfered fa sale(Section 70dd,Business � • •�1.:)0 nnd Proless�ons Code). �WNER�S P9rmit S �B f�f ;r.:� � ❑I,os ewner oF Ihe p�ope��y,am r*c�usive�y ce�'�octing wirh AUTHOBIZATION 10TA1 FEE ' � ' ' `� '•" . licensed convoc�o�s ro mnshuct t!�e prolA��(�«ion 704e, i Hn��Ai TH T Da'F a ca+-c>tt wrt��[NE 1+f4LeN N4Y(O CON nao��o Business arul Pro(ecsions Code). CO^+^�C7 7r+t nxOv[oescR��exisaNe o+rtn�r:c,ro rNc v�x��c s�v+Fe u,4 U Q—Q� CONSTRUCTION LENDING AGENCY •�i c__,� G`� � tiereby aHirm �hot 7Fere is a consfruciion lending agency ���ED TM•5 D ��NZ� ► � !or �be rfonncnce cf rhe wak fer wh�ch �his erm�t is a''��� Pa P ON'+F.S nGFvi iaued�Se[.3097,Civ.C.). � ' PDORF55 Lender's N�me lender's Address 1 certify�ho1 I hnve reod ihls oppilco�ion and:'oie�ha�Ihe o6ove iniorma!ion is correc�.1 ogree to comply wi�h oll Couniy ordinonces and S'o!e lawi regula�ing Plum6ing ond Sewe�s, o�d here6y au�hor�re reproseniotives of this Couniy to enter on obove•manlioned property fcr inspetlian purposes. ��r/', � .�A.. 9-�-s3 Signalore }Pe millae Pate SEE REVERSE FON EXPIANATORV IANGUAGE n �.�.ti �� � \ qC�'~, �`. ��f��%':� (� �" -- •')� ```,j,�;' 'C� f'j�C 7 t', W :•%��C�`�^v`�.,' v "'� �+��� �G. :,(\ `; '�= ;yr � <"': :r� �,'�. ,'` � �y\,��,, �y�' I . .. �`>✓� •CI �..M . . ' `', { ij� ,�. 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