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� WORKERS'COMPENSATION DECLARATION - �
I hereby affirm �hat I have a certifimte of consent to self
insure,or o certificate of Workers'Compensation�nsurance,or �anaazu � �
a certifiad copy thereo4(Se�.3800,Lab C.) ��d�ejkLV.1fe3� qppLICATION FOR PERMIT �
Policy No. Company
❑Certified�oPY is hereby fumished.' � ' SEWER - SEWAGE DISPOSAL �
�Certified copy is f�led with the caunry building inspection COUNTY OF LOS ANGElES BUILDING AND SAFETY
deparlme 1.
Dme.��Applicant RRiTCR T., ARRRV fOR APPLICANT TO FILL IN CONNECTION DATA
CE TIFICATE OF EXEMPTION FROM WORKERS' eunoiNc
COMPENSAiION INSURANCE nooeess 1446 S. VALEVIEGd DR. STATION DEP1H
(This sectian need not be completed if�he work involved by ihe �aA�„YDIAMOND BAR M4NHOLE REFERENCE uva�R
permit is for one hundred dollars($100)or less.) � ER
I certify thot in ihe performance of ihe work for which ihis �RouSS ivveoFcoNNeCiiON tEMGTHFROM
peimit is i55ued,I sholl nof employ ony person in any manner �� CURB P i M.i.7o v.L.
so as to become suhject ro the Workers'Compensption Lqws. P C.�+o
OWNFR B �% CO IMP.NO. 1pB NO
Date Applicant ��RE55 31,11 nIR.T�[iY t1Y1'+. SUITE N TRUNKPERMIiNO. ROAOGERMIiNO
NOTICE TO APPLICANT: If, after making �hiS Cert�f�ca�e O{ ��Ty iEl NO AFFIDAVIi WAIVER EASEMENT RECORD MSiR ND DATE
� Snpfion, you should become subject to the Workers' iE�ai
Ypensotion provisions of the labor code,you must forthwith nescamT!ON �or No 8 rfwy oa sr.wioeNiNo
cvmply with such provisions or�his permit shall 6e deemed 42554 �
re�oked. � eioa iRACT STAiE ENCkOACHMENT
LICENSED CONTRACTORS�ECLARATION nb oc eteGs PEaMiT No �
I here6y affirm thaf I am licensed under provisions of Chopte� SiZEOF�OT NOwoN ipi
9(wmmencing with Sec�ion 7000)of Division 3 of Ihe Busi- auuoiNcs SINGLE F�ILY P.ESIDENCE
ness and Profass�ons Code,and my license is in full force and. CHne�es
2F+fft. CONTRACTOR B�'�[(�L�'.� L'�I�,'i. iy](�'• CONNERION CHARGE FEE
L�ce�seNumber1�nQ(1(�_licClass $ nooaess 315I AIRWAY AVE. SUITE N REIMBURSf.MEMF4E y
Contracro�B�1MEILEA CALI$me CD—2.(0—R l�� � DISiRICi NO cuouP nnaa vaocesseo er O
CIiY , iEL.NO. 6K PG V
❑I am exempt under Sec. of ihe LA.Co. uCeTiasc No4O9E71O ctn55B Y" o
No OESCRIPTION OF WORK ree H
Plumbing Code and/ar Sec. of the rwni
•MOl15E SeWER CONNECTING TO OAiE / VI,LI ATION �
B.&P.Code for the following reason aueucsewea 7l�y (/S �
$EPTIC TANK,SEEPAGE PIi 02 FINAt �
PIiS AN�/OR DRAINFELD �f� g
Date PRIVATE D SE�SONNE TEµG TO g� ��
$i9�OtU/f � u�� CONNECI ADDITIONAL BIOG.OR ►
OWNER-BUILDER�ECIARATION woeK To r+ouse seweR
OVERFIOw SEEPAGE vIT DRAINFIEI�
I hereby affirm ihot I om exempt from the Con �or's License � exrN,cessvpo�,oavweu.nnnNHOt: �
Law for ihe following reason(Secton 7037.5,Buisness dnd Pro- niT¢e,eEvnik oa nBnNDON House
�ions Code)� SEWiR OR Di5PO5A�S�SiEM
.J I,as owner oF fhe property,or my employees with wages as •�' I � •}.&��
iheir so!e compensation,will do the work and the shvcwre #:. ,. o e � G
is not intended or offered for sale(Section 7044,Business
and Professions Code). OWNER'S Permif $
�I'as owner of the property,am excfusively contratling w�th AUTHORIZATION TOTAL FEE 27 rj0 � '" °�:7.`5�'
�cEnsed contractars to construct the projecf(Section 7044, I HAVE/+�tN15 DAtE A CONiRACi WIiH iHE HEREIN NAME�CONiRACTOR TO e •.v n�����)��U
Bu3ine55 Ond Professions�ode'. CONNEC7IHE FBOVE�ESCRIOE�EXISiING UWELLING TO iHF.PUBIIC SEWER "
CONSTRUCTION LENDING AGENCV T�f , C Z O�""S 5
I hereby affirm Ihot Ihere is a construc�ion lending agency SIGNEDTHIS_.��n DAYOF �uN� iq
for the performance of the work for which this permit is owNeeoa �� �
� OWNfRSAGENi
issoed(Sec.3097,Civ.C.). noozess Af WA G TTj TF sN ('0 'l C(�
lender's Nome TOROIv'TO DOAfINION BANK
lender'sAddresS SAN FRANCISCO� CA.
I certify ihaf I have read �his application and stote fhat the �
a6ove information is correct.I agree to comply with all County
ordinances ond State laws regulating Pl�mbing and Seweis,
ond hereby authori:e represen�atives of this County to enter
upon the above-mentioned property for inspeciion purposes.
- a3..._...�-�. �a�__�Iz.�,/a:�--
$ignafure of Permittee Date,,�--�— SEE REVERSE FOII EX�tANAiORY LANGUAGE
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