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�il �1;ORKEfiS'CON.FENSATIC'J DECLARATION �
I F i Ifirm I!+ci I have a cerriifcoie af consr.nt io self � • If.
1 i�u e� -cerhhcote of WorWers'ComPe�an:;on Inswl�nce,or t �rne<:o. 1ti:
-�r :er;�ca r.opy��Meoi�Sec,3800,Iab C • "� ,��e�e1� APPLICATION FOR PERMIT
PnI�cY No.: CompOny 1 _ �. .Ys
❑Cei�•f�ed copy is here6y furn�shed. �. SEWER • SEWAGE DISPOSAL
❑Ca�r��ed copy+s t��ed wi+h ihe coun�y bu�IJ��c�irsnec+�cn ..COUNTY OF LOS ANCELES BUILDING AND SAFETY
dena+tment.
Dare . Appl�cam FOR APPIICANT TO FILL IN CONNECTION DATA
.' CFRTIFICATE OF E%EMCfION FROM WORKERS' aun.�nc
CCLVIPENSATION INSURANCE � �ooccss � '�_ `rnrov ,t� �rN 6 �,.�
(This tac�ion ne�u no�be compleiad i(the work involvad by t!ie i«piirY �/ MA\•N'JlE QF�ERfYCF r'O �'P°fp
permif is fw one hundred dollors(5100)or � ��
I :e�'�f iF.o� in rhe rformance of ihe wk f«whic �his `i"°F'r iv�occorwnn�� LN,^�IHfGOM.
Y PS CRp55 ST. Y. CL'R0 �L M l f0 P l.
m��is�ssued,I shn�l no�employ y pe son any ner o��,�
so ns!o hecome subject�o�he Wo i Co pe �ion L s. p.,�.�a � � CO ivv.n:0 J09 Np
��� i4U�lKPF+'h`ITI:'� P:.f.7PF9M'T+A�.
Dote �/d Applicanl a^'W[55 t
NOTICE TO APRICANT: If, of�er mnk�np rh Cenif�co'e ef �iTv �'q rn�� hn � � P'-'-"�'T `'+"'�'-� rauxe•a ai�c.:���s��r r.� m�e
F.emp�ion, you should betome subjec� t ihe Workars' �F�i
Compeneanon pro�isions o�the labor code,y musi forrhwiih xt u�,+r:ya ior u� HNY fR$T Wi�[Y'NG
campiy wi�h svch proviaiona c��his permit sholl!x deemed
revoked. �^ce �aa:.r a :��:e[r:tuea:���.�r�.r
LICENSFD CONTRACTORS DECLARATION "'��"B'�i5 �pV'�
si:e c-�c� r.rw ca ic+
I herehy affirm Iho!I or�litensed under provisions of Chaplrr ��� .
9(commencing v.�ith Sr:tion 7000)oi Division 7 of ihe 6usi- au:io��+cs cHnac�S
ness and Professions Code,ond my license is in full force ond
eHeU. ccv�ana;n CC1tiE.T:CV CH59p[fF[ Y
d
License Numb�r lic.Class �o�ss Ig � U if�YB'JRSEMEYi i{E Q
Contr«ta Doie o�<m�a�+o ca��.:�, vnv :.a:x'.rssro ur V
C:TV 'fl NO �,..
❑I om e=em i onder Sec. of the l.A.Co. ...ar[ �'C. PK ,. }� O
P ��CFr.s[r+o C�n55 �U O �� a' !
P!unbinqCcdeand�or5et. ofihe CeS:.:IF11vNOFwORK rEE ,,;� W
I � !ous���R cow�cura.ro � ^�•e s `��,C VALIDATION N
B.8 P.Code lor�!•e follow�ng reason
sEvr�a�wc.s[fen�r:t a� 2
P�iS W+D�OQ ORAINfIEI� ��N°`
�OtP w�._iy.SpyyER C(MvfvECf:NG 10 Fv / ��
Mtn'A�E p5P05/�l SK�EM 4' �
Signorure ccxxrra�oon�i s�c oa
OWNfR-BUILDER DECfARATiON �`'°K��"�''��`�p �;;
.6W SfFPAGF q.ORR:NF[lD ► :.�� • ..�.i i1
I heroby off��m�ho�1 om e�emp�from d+e Con�.oc!er's lite^se e.na,cEtwx�! uxrmu.r�n�m�oir
law fo•ihe follow�nq reoson(�!1[t0��O3I.S,BV�S�BSS On(J Pfp- A�1FP,3FobN OR AyApp�i+.7.1V .. e • . • � �
�9 IG^S CO(IPJ: SkMY O4��S�JSA:S•SIFN �
� -�I,as ownxr of�!+e proper�y,or my employees wi�h u•oges ns � ° °� ����
�I�eir sole compensaiion,will do ihe work ond�he s�ruc�u•r. _
I is noi in�xnded o�offe�ed fc�sole�Sec�ion 7044,Business ^ ' '� �•v l:i�
ond Prc�essicns Code). OWNER�S PCrmil . S 0
� ❑I,as owner of�he�rnpe�ty,am ezciusively contrncring wi•h AUTHORI2/1TION TOTAL FEE '��'� �'—�'7
lice�sed con'roc!or5�o tons'rucl thp F1�0�2C�($BCIiO�7044, I MA�F AT ill'S C<iE.S CON7CK7 W:M INE wFVF'N NnuF�CCY'R1CfOR!.'J
BUSiI!B55 O�l'I FfC�P55i0�5 COfIPJ. CC�ti�Ci iNE 4BOVE OfX4�Bf'J Ez�S1iW^,OMrE;I�'uG 101�iE�t,'B:�C YWF4 �
CONSTRUCTION IENDI!JG AGENCY ('�^ ►
I hereby offfrm thot Ihere �s o consiroci�on lendfng ogency SiGNEDiNiS CAYOF � 19j[„/ .
for t1,e pe�famonce ef the •.vo•k for wh�ch fh�s pe�m�t fs °�"�"�4C10 " �
�ssued(Sec.3097.Ci�.C.J. oN•vfus n;{n•i `
A�F�E55
Lender's No^ie �
Lender's address '
I cer�ify�het 1 have read ihis applicar�on end s!a!e tho��tie
above infermotion is cor�ect.I ag�ee to compiy wi!h oll Coun�y
ordinonces ond S�ot lows�eguloiing Pl�mbinq and Sewers,
and hereb uthari e A�asen�o'i s oi lhis County lo r.neer .
upon fhe ve-me ion p�ope�y or inspeclion purposes.
�.�d, �
Siqnotu�eo Permiii Dnte SEEREVERSFFOREXPLANATORYLANGUAGE
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