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� WORKERS'COMPENSATION DECLARATION , � � �
I hereby,affirm that I hove a certifiwie of consent ro self � �I
insore,or a certificate of Workers'Compensation Inwiance,or ��nRezo . '., � , � U
a certified copy thereof�Sec.3800, .) � �� `-i°°°ikEv.vbii qppLICATION, FOR� PERMIT
Poliry No.� y �
❑Certified copy is hereby furnished. SEWER - SEWAGE D15POSAL �
�' ertified copy is filed wirh the counry 6uilding inspection COUNTY OF LOS ANGELES BUILDING AND'SAFETY
dep tme t
Date�E?��U.�APPlica�' i- fOR APPLICANT TO FILL IN CONNECTION DATA
:ERT�FICATE OF EXEMPTION FROM WORKERS' suaoiNc
COMPENSATION INSURANCE � nooeess STATION oevrM
(This section naed not be completed i4 the work invOIv2CJ C � MANHOLE REFERENCE UPPER
�permit is for one hundred do�lars($100)or less.) � LOCFi11TY iowee
I certif that in ihe erformance.of tfie work�for wh(ch this �ARE57 TYPE OF GONNECTION IENGTH FROM
Y P �Ro555T_ Grand Ave. & Summit Rid e Y. CURB P.�. M�*oP�_
permit is issued,I sholl not employ any,person in any manner � v.c.No.
so os to become subject to the Workers'�Compensation laws. owNea gramal ea L i mi ted n �IMP.NO. JOB NO.
-Dafe Applicanf ooRE553151 Airway Ave, Su�te t`I TRUNKPfRMITNO, ROADPERMITNO,
NOTICE TO APPUCANT: If,.after makllj tflls Celtlflmie of AiFiOAVR WANER EASEMENT RECORO.INSTR.NO. DATE
9 CITV TEL NO. _
' 'qiption, you should become subjecr to ihe Workers' LEGAL•
ripensatio,n prov�sions of rhe Labor code,you m�st forfhwirh oesccivrioN iorrvo 29 MWY.ORST_WIpENING
comply with��such provisions o�this permit shall be deemed 42556
�EVoI(B(I. � � BLOCK iRACi STAfE ENCROACHMENi
LICENSED CONTRACTORS DECIARATION � - nio of eiocs PERMIt NO
1 hereby affirm ihot I am licensed under provisions of Chapter s¢eOFiOr Now ON iOT
9 commencin ith Section 7000 of Division 3 ot�he Bus�- use oF
( s w � BUILDINGS Single Family Residence CHARGES
nass and Profossions Code,and my license is in full force and
CFFE[f. CONiRACTOR QY'ama�ea Ca��f. I(�C. CONNECiION CHARGE FEE
License Numbe�Qn��� LiC.C�a55 Q � pDDRE55 3151 Ai rway Ave.� Su i te N REIMBURSEMENT FEE � }
COnffaCt�Firamalea Cd�lfOme 6/6/85 � c�Tr 1E1.N0. DISLRICTNO. GROUP MAF FROCESSEDBY O
❑1 am exempt under Sec. of ihe L.A.Co. u[eNse No. eK v� V
srnre 409610 ciAss B �{� ��
�
NO. DESCRIPTION OF WORK FEE
PlumbingGodeqnd/orSec. ofthe fiNAi VALIDATION �
HOB 5�E�R CONNECTING TO � P'y/�� DATE
t.Sla
8.&P.Code for,tha following reason $EPTI�TANK,SEEPAGE PIT pR �
' GITS AND/OR DRAINFIELD PoNA�
Dq�B HOUSE SEWER CONNECiING TO eY
n PRIVATE OISP�SAL SYSTEM .�
Signa�ure� '-'d� CONNECT ADDITIONAL BLDG.OR ,
� OWNER-6UILDERDECLARATION 'NORKTOHOUSESEWER , :
I here6y affirm ihat I am exempt from the Cont se �xiNF��esS�cooiGoxrw�RAMnNHo�e �
Law for ihe following reason(S2CIDft�O3I.S,BUi5f1e55 O�CJ Pf0- ALiER,REPAIR pR ABANDON MOUSE
Of15 COGEJ: - SEWER OR DISPOSAL SYS7EM
�.
u� �a owner ui ine properiy, iiy e�npioyeea ii� woyes as
� their sole compensolion,willydo the work and the strucfure , �C 7 L.3 A "
is not intended or offered for wle(Section 70G4,Business
and Professions Code). OWNER'S Permit S �Q �j e n � �. } Q
❑i,as owner of the property,am exclusively contrac�ing with AUTHORIZATIdN TOTAL FEE � Q � � v 2 7�O _
licensed contraaors to construcr ihe project(Section 7�44, 1 HAVE AT iH15 OAiE A CONTRACi WIiH THE HEREIN NAME�CONTRACiOR TO �
BUSin955 pnCl PrOfe551on5 CodeJ. CONNECT iHE A80VE DESCRIBED EXISTING DWELLMG TO THE PUBLIC SEWER � � ���,`)n U
CONSTRUCTION LENDING AGENCY � •
I hereb affirm that fhere is a consfrucfion lendin a enc SIGNEDTH DAVOF ��� 1 [ ,1 f�G
Y 9 9 Y OWNEF O ► O V'� 4 i'"`J
for the performanca of the work for which ihis permi� is owNeas nc[Mt`� �
iswed(Sec.3097,Civ.C.).
Toronto Dominion Bank A°°RESS
lender's Name �
lendar'sAddressSan fransisco ,
1 certify that I have read this application ond siate that the �
above informafion is correct.I agree to comply with all Counly '
'ordinances and State laws regulating Plumbing and Sewers,
and hereby authorize represeMative5 of Ihis County to enter �
upon the above-mentioned prope�ty for inspection purposes. .
�-sa�.d�. LO �� � �
45ignoture of Permitfee Dafe � SEE REVERSE FOR EIIPtANATORY IANGUAGE �
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