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1364A (7)
� WORKERS'COMPENSATION DECLARATION � � � � �� � � �. -� . ' � � � I�hereby �ffirm li'iat I hove a cerfificote of conseni to self��. ' �� . �,, . � Insure,or,o certifi<a�e of Workers'Compe�rante,or.... �ansszu . � . . , . . . Po�crfifiedco y e t�pan800, C.) � .. ..�EBoe�aE�,e,e�� . ::.:;APPL�ICATION: FOR.'.:�PERMIT - ._ . . - �� ❑C��ied co��eby fumished. �� _�f � � � � -. .. . ,,. SEWER - SEWAGE DISPOSAL , . . �, ❑Ce�rHed copy is filed with�he toonty building inspection COUNTY pF LOS ANGELES BUILDING AND SAFETY departme�i. � -• Datc Applicant_ FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' eoitoiNG � � i s7anoN oEPTH COMPENSATION INSURANCE .. � aooaess I 11 I 1 � �VZ%' � . UPPER � �'�This section need not be completed if ihe work involved by the � �, �tl vaNxOie ae�RFNce �owee � �ocnutt -'� permit is for�one hundred dollars($100)or less.) NEAaEsi �r./ rvaeoFcoNNecnoN �Ncni Faom 'I certify�hat in she performance of tfie work for which ihis CRO55 5'. � � • ��'� Y. CURB a.i. M.:,io P.t. permit is issued,I shall noi employ any person in nny manner . P.c.uo. . - '�sb as to become suhject to the�Workers'Compensation lows. Ownefl (�l 1�� � �� f��!Mo.NC. JOB NG ; - MAIL � � L r TRUNK PERMIT ND. ROAD PFRMIT NO. , ADDitES ���g A�JPIiCatlt AFFIDAVIT WAIVER EP.SEMENi RECORD.INSiR.NO. DAT[ -' NOTICE TO APPLICANT: If, after making this Certificate of �iTy -� t.No. ��r�� ��mption, you should become subject .to the Workers' � �EGat �ipensdtion provisions of ihe�Labor wde,you must farthwith �� � oescaiviiON tot No. nwy.oa sr.wio¢NwG . `-; 'comply with soch provisions or ihis permit shall be deemed (/ c'[� . �:�.�.�'"'l9vOkE4�. . , BLCCi: iRACT i� $1ATE ENGROACHMENT ,,;���, . NO.OF BlDGS. FERMIi NO. LICENSED CONTRACTORS DECLARATION ; 5izeoF�pi r+ow on�or _ _ `'`�i 1 hereby affirm that I om licensed under provisions of CMapter __ _' �E eP . - '.'.-9(commencing wilh Section 7000)of Division 3 of�he Busi- euuoiN�s CHneGES � � '`r ness and Professions Code,and my ficense is in fufl farce and . ' ' CONNECiION CHARGE FEE � } � CONTRACTOR � �•'"effect. J� - {j REIMBURSEMENT FEE u , �� License Nvmber � �`� Lic.Class__ � , � nooRess �ISTRICi NO. GRCIUP MAP ?ROCESSED BY ��• COn!�OCtOfg cz���/'��P�O � CIiY iEL.NO. BK FG (� ", Z. , STA7E �: LIc. �\� O . � ❑I am exempt under Se<. of the L.A.Co. . ' uceNse no. � 7l a^SS �=� �A�.- e .�� � . Plumbing Code and/or Sec. of the . No. D CRIPTION OF WORK FEE . �ous�sEweR mNNecriN�ro f GV �aTe `y f 5,�/�� VAIIDATION � � B.&P:Code for�he following reason Nusuc sev�ra /! / SEPiIC iANK,SEEVAGE PIT OR HNAL • Z - PITS AND'OR�RPINFIEtO S � . � Dpie _ . av , HOVSE SEWCR CONNECi1NG i0 �.p� � PRIV�iE DISPOSAL SYSTEM ' $i9natufe . CONN.�i 4DDI?IONAL Bt'JG.OR � � � 01NNER-BUILDER DECLARATION woRK To noos�seweR . OVERFtOW SEEPAGE PIT,DRAINFIEID �, I hereby uffirm that I am exemp�from�he Contractor's License ezTN. cessvoo�aevweu,enn.NHoie - ��Law for the following reason(Secton 7031.5,Buisness and Pra SEW[R OR DI5Po9ntBs 5o N NOUse 'jyons Code)� � �- �� �"I,as owner of ihe oroperty.or my emnloyees with wn�Pc n� �� �heir sole compensation,will do the work and the siructure is noi mtended or offered for sale(Sec}ion 7044,Business , OWNER�S Permit $ ('} ,;,`A I ti�.4,��j ' ' and Protessions Code). � ALITHORIZATION T ` � � " �;Q I,as owner of the property,am eadusively contracting with � OTAL FEE . �� � 2'].5 C licensed controctors to construU the project(Section 704a, � i HqvE Ar mis onTe a coN�ancr wrtH rHe�+eReiN NnMeo coNtencroa ro . ��� 1 BUSiness and PrOfeS5iOn5 COf1BJ. COUNER THE ABOVE OESCRIBED EXISTING DWfILING i0 THE PUBLIC SEWER. � � ': �•v .Ci� ' �r �—i CONSTRUCTION LENDING AGENCY �y / ''t%S C�t�'"'�5� : SIGNEO THIS�_DAY OF��� • 19;I ' �.��I hereby affirm fhat ihere is a consirucfion lending ogency ` , s OWNER OR �'.for.the performance of t he wor k for w hic h t his permi t is - owrveas ncFN*__.�l'"w'^/l G l�`�^ �ie��'+�• :��-issued(Sec.3097,Clv.C.). y4� vr, )„1 /' . aooREss �!� �=Jw �� �,�i_ ������tender's Name ��'���j� ��Q�.�� � ��.����Lender's Address_ C�.1h. 1'�f-Z� . � ? � , .-�.1 certify that I have read �F��s applicatien ond sla�e that she t � .��above iniormation is rorrect.i agree to comply with all County . � `�.�ordinances and State laws regulating Plumbing and Sewers, � < . ',�,and hereby authorize epr entatives of lhis County to enter � �:'upon the abov -me�ti ned r rty for inspe tion urposes. � . � � ' Signature o Permiitee Dafe SEEREVERSEFOREXPLANATORYIANGUAGE i � � i . . . �� �o .�.,. . , ��gZz �'�° � ���� (� n � .y.m Zm �y O b-� Zm S �y S� inD o2 �� C n c'� c3'� Q ba'e �O� '�", � � �ii D '�"^y�j �`� rni � Ki �O � �o mz ��' �b �g � �o rR � � � O�p � A O O v �A � ~ D � y � � � H ` � 1 � � \ � a° \ m V I� � ► �� � . I � o � � � .� �' � � � � � � � � � � �D . � rn , ! � j . � � - . I . � . � -; ► _ ' � . . , : . �� � � . � � � ., m . � . i; � 1 � ` a ►�{ N� � � ' ' . r ' , ', . - .. . . . . � , � , .. t . . .. " -<. .. . . � 'a�.r � �`'-°�G7 �1 ��`, �'y�H �� � ' . . - ' . 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