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� WORKER$'COMPENSATION DECLARATION ' � � .� � � ' . - . �- � � � � I�hereby:sffirm thaf I have o certifiw�e of consent.fo self �� �� � � ' , � . ii,'.,'�ie,or a certificato of Workers'Compensation Insurance,or ., �tna<2n . . � � � a certified copy rhereof.(Sec.3800,Lab C.) ce eos�eEv d a„�,��, .�qpp«GATI�ON�.:�:FO.R� PERMIT � � Policy No.__ Company � � OOs � C � ;� !�ce.�+f�ed copy is hereby furnished. JEWER - SEWAGE DISPOSAL .,�C rhfied copy is filed wi�th_t e counry building inspettion ": �. � COUNTY OF LOS ANGELES BURDING AND3AFETY ���� � � � � � de t enl � � �y � . ��-.. �--+� �—APPlicant -•w�st".5�� ._`�'�l fOR APPUCANT TO FILL IN CONNECTION DATA r ( CERTIFICATE OP EXEMPTION FROM WORKERS' SunowG GOMPENSAiION INSURANCE . � nooaess � � ^!� uTATION : �'�9 oevTH �,'�� (This seciion need not be completed�if ihe work involved 6y ihe n,wNHrnt REF�REwcE �_1 / UPVER . -5'� permit is for one hundred dollars($100}or less.) iocnuTv T' �owea ' NEAP,EST C' TYPE OF(:CMNECTiON o LENGiH fROM - `i�'I certify��hat in the performance of the work for which this ceosssr. e-C� ' E?. ��. y, cuea P.L M.LTOP.L ' �-pennit is issued,I sholl not employ any person in any manner �- PC NO. ;�so ps to 6ecome sobjed to the Workers'Compensotion.Lows. ��ER 1 CO.IMP,NO. JOB fJO. � ��� � - � MPAI �� �� �. �C iRUNK PERMIT NC. ROAU PEN.MIi NO. ' � . Date APPIiCaN �', ADDRE55 . '�� NOTlCE TO AGPI.ICAN7: If,��ofter makin tftis Certifirote Of - C � � C AFFlDAVIT WAIVEP EP,SEMENT RECORD.INSTR.NO. DATE 9 � ��T� � [ ,E�N:, � 1�.' 7 Exemption, you �should become subject to 1he Workers' IEGn� �� Compensation provisions of ihe Labor code,you must forrhwith � _. nesceiPrioN ioTNo. � Hwv.oasT.wmernN� � � comply with such provisions or ihis permit shail be deemed ' �o- ''7 '"iBVOkefl. ' , _ „� BLOCK TRACT `,�� / STATEENCROACHMENT � ' � LICENSEC�COMTRAC?ORS DECLARATIO�PI � mo.oF emcs. Pearnir No. 'n srzE o�ior , f" Now eN ioT �'9 hereby affirm thoi I'am licensed under provisions of Chopter ' r, �E�F � �9 (commencing wilh$ection 7000)of Division 3 of the Busi- ' euit0iNG5 cHaaGes - �nen and Professions Code,and my license is in full force and �� �'BffE�Cf. ,/�', ' CCNJiNAC70R �� r � CONNtCTION CHARGE FEE �, �License Nu�r�� �0 _Lic.Class 11�t�C9 '+ �_ a. . � ADDRE55 " REIMBURSEMEIJT FEE � y� 7 DISTRI�T NO GROl/P MAP PROCESSED BV V '.ContracfOr. t� . (1C..Dpte . ���i CI7Y . 1 "'1 7EL.N0 , ��� l eY, vG �' ' p�I am ezempt under Sec _of�he L.A.Co. � LICENSE NO pC "i"/�� cins �"� "`C L�a� .b.-^ O , PlumbingCodeartdiorSea__ _ofihe � N� DESCRiPTIONOFWORK f�e �.ir�Ai v ' HOUSE SEWER CONNECTING TO DATE VALID TION � ' _ B.�&P.Code for the following reason ,__ � "+a ausur sewea � y �'. y, SEFTIC 1AVK,SEEPAG�FIT OR F�NAi ��( � � .� ''��'. Date .,r. PI15 AN�/OR DRAINFIELO 6Y � HOuSE SEWER CONNEGiING TO� (J Y � .1. GRIVA"F�ISPCSA:SYSTFM Signpfure______ . � CONNECT A��ITI[JNAL 5lDG.OR � � OWNER-BUILDER DECLARATION �� woeK ro i�+ouse sewea l, RF��W SF�Pn'E 4�T,URAINFIFtO 'I hereby aff rm that i am exempt from the Contracror's license �'� extN ce.svooi.,ourweu,MnNHoie ' `Law for the fol�owing reason�Secton 7031.5,Buisness and Pro- � niiek REaaut oa aanNuoN HOuse � 3i '�����;.;!'�.1e�� ' �, SEKEk CP�5-vSA�_SYS:EM ��. ti: ;❑�I,as owner of the properly;or my employees with woges as � "' , Iheir sole compensation,will do the work and the struct�re �dJ�� � :is not intended or offered for sale(Section 7044,6usiness �' �a Permit g Q '"a -^'I :i?3 A s''> and Professions Cade}. ( OWNER'S � ❑�I,as owner of the properly,am ezclusrvely contracting wilh � AUTHORIZATION TOTAL FEE � sl`? }�.a c g�m T C � r licensed coniroctors fo wnsiru<t ihe projeU(Section 7044, �`. �HqyF qr TN�s o.aTE n mNrknct w�TH iMe HEPE�N NqMeo coN aqCTOR ta � � ,8usiness and Professions Code). � CONNECT iHE ABOVE�ESCRIBEU E%ISTING DWEILMG TD THE PUOLIC SEWER � �,���'J�� i � � CONSiRUCTION LENDING AGENCY �� � I hereb affirm that there is a construction lendin a enc , �' SIGNED THIS DAY OF _t9_ ► F ��' � ;"s�;' Y 9 9 Y 3 '= G /..,v c. for ihe periormance of ihe work ior which inis permii is ','��; �NFa�k � : OWNFRS AGENI �j �'issued(Sec.3097,Civ.C.). �e� !1 t;c�.,.•.L�b �Lender's Name K� Ao�Ress _ �.tender's Address_ �,�;� .. � ;I ceriify ihaf I have read ihis application and stafe ihat ihe i" �above info�mation is cor�ed.I agree to comply with all Co�nty �� - ,ordinanr.es and Stote lows regulating PIum6ing and Sewers, :. � . ' a hereby authorize rapresentatives of ihis County to enter ,Pr , �-i u 'n the obov meMi ed property for inspection purposes. r - � �.. �-�� �} _., Signafure of Permiflee Date . SEE REVERSE FOR EXPLANATORY LANGUAGE ��� � � �1,�',r'. � ,,t".'�.&' .,�.;.�;..�, ... , � �� . . ..-.;� .:5..t..,.. , ysa�8 � .A ,-- .., - ., o�2� �p � z�OZ � . �z� � �� � � � �- �� � �� � �� g� N � . ' Q� ��� m� A�� � o ' a �4t g'� G �!-'�'��,�..� � �fl�6 �`� � " �n F � � � � Q � O � m '� , b � , N � � H a � � A m S � { . .. ' ` . � ' . �M � :�1 $ _ � � ^ ' d !TA . � . ��. .�..'�.��.�� '.` Y� . � � -a++ "`�w`' � '�'S.����� a A ��Y`� "c � . . . 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