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1758A (10)
WORKFR$'COMPENSATION DECLARATION � I he�eby aifirm ihat I ha�e a certi(ica�e of consent to sel( . insure.or a certificoie of Worke�i CompensaHon Inauronce,or 1M14fA]D S a«�,,f;edcopy�hereol(Sec.3800,LobC.) �E��°�°e�°�� APPLICATION FOR PERMIT Policy No. Compony ' '�s ❑c :r;��oPY�5 ne�e�Y F���,sh�,. SEWER • SEWAGE DISPOSAL Ce�r��ed copy+s f��ed w�rh rhe counry build�ng inspecrio� COUNTY OF LOS ANGELES BUILDING AND SAFETY depanment. ' oeie Appiiconf FOR APPLICANT TO Flll IN ,U�L�[' CONNECTION DATA CERTIFICATE OF E?(EMFTION FROM WORKERS' n l • COMPENSATlON INSURANCE �iss �l �L 4 Y w`p 5 4i��y ��]S OF�TH (This seclion need nol be comple!ed if Ihe work involved 6y Ihe �«�iin, �•'T .WNi�^!C YFFFYFNCF � � permit is for one hurdred dollors(f100)or lets.) I cert�fy ihoi in�he periormance of �he work For which�his CQ�ssssr ivoco�cotir�rtci�o.� IFNGfNFROM ,' Y. CVRB Pl� Ml IOVI. 1' permit is issued,I sholl no1 employ nny persan in nny mnnner � � � .� '� 50 OS 10 FilCCmG SUE;PC��O iti�WOrk!'S Com enu�tlon lows. v c.No ('�� 7 � , P p.A.•:[4 T [� I SC4.f CO Ih'v.N'J J^0 NO J I�J ��� iiUNR oEiM�I NO ROip GEYMii NO � Dote Appli[ont a�cRf55 J a'C � � �` �7 ♦Fi�AVIi M'A:`hW FPyEM(!:1 RECLw7�wS:R NO D4�k J NOTICE TO APPIICANT: If, oher mokinfl ihis Ceriifito�e of �iT� r r,���p / � /6 V Eaemplion. you should become subject �o �he Workers' Compenso•ion provisions of ihe Lobor code,you musl(orrhwi�h pEscaiGr��,^,v �Cr no � MWY,C3 ST WI�41\.^s 'y comply wi�h such provisions o�this permil shall be deemed �� revoked. BiocK +:<Cr � SfI�IFfN�4p4CYMfYf r LICENSFD CONTRACTORS DECLARATION ��&�5 ��f��� 5i7E OF�C. �G 6 .�OW a�0, I hereby affirm ttiai I ar�licensed undar pravisians of Chap:er i�� � 9(commencing wi�h Section 7000)o(D�vision 3 of Ihe Busi- bu�i��•:cs L .P S ( J H o�aacts ness and P�ofessions Code,ond my license is�n iuil force and _ � effecl. ca�:rRatiOa CONn:C7'ON CM4RGE ifE . License Number Lic.Class q.N,�ss rtew�a�:ostv[nr r�t Conrroctor � Do�e orr •;Et.�a � — "sc:'c�+a. coouv .,w= PYOCESSFD BY sare 7 BK/ / � ❑I om e.empi under Sec. of ihe l.A.Co. i,,p�;c;n;� cuss (�� ,� �V �'I/f �J (�!�-��,��/^'� NO (yCCG'GT'ONOFWORK if[ . PlumbingCodranJ/or5ec. ofihe �rvni • IC::��CSFNERCCwNF.i'NG'� � =:.rr VALID TION B.8 P.Code lar ihe foilawing reason p1°°'�'�P � ...J 4P':�I�Yk.$Efo�'.<:�.1 f:u iivn ni.5 nv�•OR Pin rv��Fl� ' Dale �+OUSE SEMN CO�w+EC':NG!O BY ' GN�VA'E G�S�'.^.SAL 5�5'EN $+gra`ure L'J0.VF:l a'ti:'�,7:5L tl:J!;UR , OWNER-BUIIDER�ECLARATION W�»��X SF��YfN , CVE i W SEf1's{�(P.1.�Yia.M�i:;J I hareby oHirm�hot I am e.empt from r!�e Con+rocior's License [�ia,�E55voa..:wrv.s;i wv.wo+r Law(or thc following rsason(Secion 7031.5,Bu�sness and Pro- ..=c Reon.c cs:,�.+�a::r.��;;�,:x lessions Cede): sE sEv ov C�sw„sni Srs[M ❑I,�5 ownnr of ihe Froperly,or my employees wilh woges os � their scle compensation,will do�he work and Il+e stru:lure �= I I �v • . ' �s�or�n'er+dad cr offr.�ed ler wie(Sec:�on 7CJ4,Business and Profess�oos CoJe). OWNER�S Permit S �fJ,�' . • •'• � (i ❑I,os owner of rhe propertY,am xxtlusivcly[on�•acling wi!h AUTHORIZATION TOTAL fEE '' (' � � ��7 r,C licansed contra.iors'o cons'ruU�he prejeU(Sec�ion 7014� ���yy'r qI fHi$OpiE A CON�i.fU N'IW fl�E M4i'N N4YrJ C er ncTcw ro BVS�nE55 O�(I PfOfBS5in�5 COd@�. COM1M1F.i T��E A&:V[DfSiR��D FM•ST!�fl'A(II'r1G T.7 iME PV&'C SF`MFR '� / ,.^-.. • i(_'!..){/U CONSTRUCTION LENDING AGENCY � n I Ferehy nH��m thoi �hrrP i� a cens•ruc��e� In�ding agency SiC,NFDTNiS � AVOF J � Io� for �he parformonce cf the werk for which ihh perma is �'`'�'�RC° , V� issued(Sec.3097,Civ.C.). Ov.':txs n,^,t ��.C�— !.D^+'FSS � v Lender's Nome Lender's Address . I certify thot I havr. reod ihis aapHcaGon ond s�a�e ihai ihe. � obove informa��on is co�rect.I agree 10 comply wl�h all Co�nly ordinonces a�d S�n�e laws�equlo�inp Plumbinq ond Sewnrs, � and hereby a�thorize rep�esenro��ves cf�h�s Coun+y ro entar �°�r1,e abo�e-menl�oned p�operly(or inspecfion purposas. �—�Y7 r`..0�rJt._—. ! `G^ �3 , i— g�nnlureofPermit�ee Do�e SEEREYERSEFONEI(PLANATORYl11NGUAGE h ry (" 1 � ���. �1:�) � � ^ , • �.^� i.` ll�l "' () y-� ( S�{:� �1�t� �� J��� �(^ ( J''�` f. r �.:r i� ��, n�V� �•` (+�% �tl� � � ,.0 � . C,' �'s. 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