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HomeMy Public PortalAbout4700 MILLER DR_Sewer__ NKERS'COMPENSATION DECLARATION y firm that i have a certificate of consent to self insure, or a certificate of Worker's'Compensation Insurance, or 76A642D ticer� th f (Sec. 3800,1atLC �j� CE 808(REV.B:'81) APPLICATION FOR PERMIT •PoI .T�ltr_ CompanY ,,.,..�✓=� �. to ❑Certified copy is hereby furnished. = �} SEWER - SEWAGE DISPOSAL Certified copy is filed with the county buildn. inspe ion COUNTY OF LOS ANGELES BUILDING AND SAFETY de art ent. Date �`` Applicants FOR APPLICANT TO FILL IN CONNECTION DATA CER FICATE OF EXEMPTION FROM WORKERS' BUILDINGrz COMPENSATION INSURANCE ADDRESS STATION / DEPTH (This section need not be completed If the work involved by the LOCALITY r MANHOLE REFERENCE15 7^l L E permit is for one hundred dollars ($100)or less.) / � L T IF NEAREST TYPE OF CON TION �// LENGTH FROM I certify that in the performance of the work for which this CROSS ST. Y /y0 .r(L.. ro P.L permit is,issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. OWNER ` _ CO.IMP.NO. TC 841- MAIL �' "'� F TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS t / 'f- / 1 NOTICE TO APPLICANT: If, after makingthis Certificate Of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE CITY TEL.NO. Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT No comply with such provisions or this permit shall be deemed HwY OR ST.WIDENING revoked.- BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION No.OF BLDGS. PERMIT NO. SIZE OF LOT NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter USE OF 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS ' (t/j !r CHARGES ness and Professions Code, and my license is in full force and effect. f �... CONTRACTOR `- s CONNECTION CHARGE FEE Contractor >F'� �� ate ADDRESS � �.y REIMBURSEMENT FEE License Numb a a.. �LCIfaS 6„ ;7 DISTRICT NO. GROUP MAP PROCESSED BY u � � 7 CITY (✓ TEL_NO O. 1 BK PG STATE LIC s ©tj „/� ❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. _- CLASS (e� NO. D CRI TION OF WORK E V Zi Plumbing Code and/or Sec. of the FINAL VALIDATION A.Z. HOUSE SEWER CONNECTING TO DATE ,�' �" B. & P. Code for the following reason PUBLIC SEWER SEPTIC TANK,SEEPAGE PIT OR z PITS AND/OR DRAINFIELD FINAL Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature i CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD :. I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE 1 Law for the following reason (Secton 7031.5, BulsneSs and Pro- ALTER,REPAIR OR ABANDON HOUSE kj fe5sions Code): SEWER OR DISPOSAL SYSTE ,, r '{' 8 as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure 3307 603.50 is not intended Or offered for sale (Section 7044, Business ITEMS and Professions Code). OWNER'S Permit S {} ❑ 1, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE l9 TOTAL 60 .50 licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH REIN NAMED CONTRACTOR TO B oslness and Professions Code). CONNECT THE ABOVE DESC D EXISTING ELLI G TO E PUBLIC SEWER. CHECK 0.50 CONSTRUCTION LENDING AGENCY ff� `N I hereby affirm that there is a construction lending agency SIGNED THIS D OF for the performance of the workfor which this permit is OWNER OR issued (Sec. 3097, Civ. C_). OWNERS AGENT opt 00MI-t:�Ct i 7/19/89 Lender's Name ADDRESS Lender's Address 4562 1 AM 10:28 1 certify that,.? have read this application and state that the above inf ation is tI agree to comply with all County ordinanc nd to la s/.,e�lating Plumbing and Sewers, and he a horize pratives of this County to enter upPn �e7ab a-men ' nederty for inspection p rPOSes. ignature Per Date= SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self ( insure,Ipr a certificate of Workers'2�,,! nsation Insurance, or 76A642D a certifie,� ;h e p ny ,,y CE 808(REV.8i81) APPLICATION FOR PERMIT aolicy NO ompany '�A i�t1 �: -- -- : .El Certified copy is hereby furnished. - SEWER - SEWAGE DISPOSAL R ertified copy is filed with the count uildir.g i'n ion COUNTY OF LOS ANGELES BUILDING AND SAFETY C 40�a rt ennl.,.- Dor ' pplicant FOR APPL CANT TO FILL 1% CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' f COMPENSATION INSURANCE ADDRESS 06 �. STAnoN d S DEcrH ' (This section need not be completed if the work involved by the f' MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) LOCALITY ` LOWER t NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance o. the work for which this CROSS ST. - Y. CURB P.L. M L TO P.L. permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. P.0 NO. OWNER "tea._- CO.IMP-NO. JOB NO. MAIL Dole _ App!icant ADDRESS RUNK PERMIT NO. ROAD PERMIT NO. NOTICE TO APPLICANT: If, after makingthis Certificate of r AFFIDAVIT WAIVER EASEMENT RECORD.INSTR,NO. DATE CITY TEL.NO. ' Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT No. comply with such provisions or this permit shall be deemed HWY.OR ST.WIDENING revoked. BLOCK TRACT STATE ENCROACHMENT ` NO.OF BLDG& PERMIT NO. LICENSED CONTRACTORS DECLARATION SIZE OF LOT NOW ON LOT 1 hereby affirm that I am licensed under provisions of Chapter USE OF 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDING 'F. !L� CHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTOR CONNECTION CHARGE FEE License Numbeq Lic.Class_ } [ted CL ADDRESS REIMBURSEMENT FEE O Contract rl"JC�1e / 6 r DIST�I,CT NO GROUP MAP PP.00ESSED BY V CITY ,/ EL.NO. ? �/ STATE �' ° LIC. 3! ,�K PG O ❑ I am exempt under Sec. of the L.A.Co. LICENSE N�-,` CLASS ! NO. DES IPTION OF WORK PEE (J Plumbing Code and/or Sec. of the FINAL VALIDATION y HOUSE SEWER CONNECTING TO 012 /(� DATE x - Z�', PUBLIC SEWER lo" p B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR Z PITS AND/OR DRAINFIELD FINAL Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature_ CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER % IR OVERFLOW SEEPAGE PIT,DRAINFIELD k I hereby affirm that I am exempt from the Contractor's License EXTN,,CESSPOOL,DRYWELL,MANHOLE jt Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM ACV ,., ❑ I; as owner of the property, or my employees with wages as z their sole compensation, will do the work and the structure not intended or offered for sale (Section 7044, Business i ;- ind Professions Code). OWNER'S Permit $ ► T ❑ i as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE C" '%tp� 27 50 ".censed contractors to Construct the project (Section 7044, 't HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO• ii Usiness and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. N ECX 27.50 CONSTRUCTION LENDING AGENCY CHANGEsola I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_ for the performance of the work for which this permit is OWNER AGENT issued (Sec. 3097, Civ. C.). #? /25/' ADDRESS .(3—# I " Lender's Name 1l Lender's A fess_ 58 2 1 1i 11:11 I certify f I have_read this application and state that the above i mati�yn'is correct. I agree to comply with all County ordina c a Stat laws regulating Plumbing and Sewers, and he by authari a repr sentatives of this County to enter up e a Ve-rn ntione property for inspection purposes. Signature Of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE 6,. WORKERS' COMPENSATION DECLARATION 'I her4y affirm that I have a certificate of consent to self insure—or a certificate of Workers'Co nsation Insurance, or 76A642D a ertif ?die ompa38� C) y. CE Boa(REV.8'81 APPLICATION FOR PERMIT A& `❑' Certified copy its hereby furnished. SEWER - SEWAGE DISPOSAL Zert'fi c y is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY Applica r !'L- �a FOR APPLICANT TO FILL IN CONNECTION DATA C R FICATE OF EXEMPTION FROM WORKERS' FNEAREST , e. COMPENSATION INSURANCE C (! `. �' +C , _ STATION ( DEPTH (This section need not be completed if the work involved by the - MANHOLE REFERENCE ` UPPER permit is for one hundred dollars ($100)or less.) LOWER I certify that in the performance of the work for which this TYPE of CONNECTIONLENGTH FROM Y P permit is issued, I shall not employ an Y CURB en-11--) M.L.To P.L. p p y y person in any manner so as to become subject to the Workers'Compensation Laws. 3 P C.No. I NER .�'�"�„�) + CO.IMP,NO. JOB NO. MAIL Date Applicant DRESS �L3 TRUNK PERMIT NO, ROAD PERMIT NO. NOTICE TO APPLICANT: If, after making this Certificate of '�` AFFIDAVIT WAIVER EASEMENT RECORD,INSTR.NO. DATE Y .� TEL NO. .E.-` Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the Labor code, you must forthwith CRIPTION LOT NO. G comply with such provisions or this permit shall be deemed Hwv.OR ST.WIDENING revoked. CK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO.of BLDGS PERMIT NO. E OF LOT NOW ON LOT t I hereby affirm that I am licensed under provisions of Chapter OF 9 (commencing with Section 7000) of Division 3 of the Busi- LDINGS CHARGES ness and Pr sions Code, and my license is in full force and ffe �� CONNECTION CHARGE FEE CONTRACTOR ..ti `„rg,., :` � d '. L> e NU �Lic.Class—`.F{ ADDRESS Pg"tic REIMBURSEMENT FEE O Contractor at�ed � t 'jC � DISTRICT NO GROUP MAP PROCESSED BY u CITY 1- - TEL NO. BK PG O ❑ I am exempt under Sec. of the L.A.Co. ICENSE NO. ('' `��� class _�� M L P` &�� Plumbing Code and/or Sec. of the No DESCRIPTION OF WORK FEE FINAL lh��� v 'HOUSE SEWER CONNECTING TO DATE f ...� ` VALIDATION a SEWER PUBLIC �! S. &P. Code for the following reason h" Z SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIELD _ Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD , t I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRVWELL,MANHOLE ' Law for the following reason (Secton 7031.5, BUisness and Pro- ALTER,REPAIR OR ABANDON HOUSE 1 fessions Cade): SEVER OR DISPOSAL SYSTEM �t�.�.T 4 ❑ I, as owner of the property,or my employees with wages as 3"3 e 2 their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business i NEM and Professions Code). OWNER'S Permit $ El I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE ` !lj_AL 27 .50 licensed contractors to construct the project Section 7044, (J `P'T 51 P I ( I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO �-��.�i 4.c a•. » Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. _ #*•••• aS13 CONSTRUCTION LENDING AGENCY , .H,�''l�t�. I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19, for the performance of the work for which this permit is OWNER OWNERS A AGENT issued (Sec. 3097; Civ, C.). ADDRESS � r� Lender's Name 5884 1 AM 1 IL:15 Lender's Address I ceftify that I have read this application and state that the above informati/e,.,', rrect. I agree to comply with all County ordinances and r ulating Plumbing and Sewers, and hereby autepres ntatives of this County to enter upon the abovenedperty for inspection purposes. Signot e ermitt (r'y Date SEE REVERSE FOR EXPLANATORY LANGUAGE G-' WORKERS'COMPENSATION DECLARATION I he.,teby affirm that I have a certificate of consent to self ,- -insure, or a certificate of Workers'Compensation Insurance, or 76A642D a certified y (Sec. 3800, C. CE Bos fREv.a,<Bt I k?oIicy Company �s APPLICATION FOR PERMIT Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ' t Certifie cepY is filed with the couT uildin inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY dP or et— Date Applicant FOR APPLICAPY TO FILL IN CONNECTION DATA CERTFICATE OF EXEMP ON FROM WORKERS' BUILDING 49 COMPENSATION INSURANCE ADDRESS STATION DEPTH (This section need not be completed if the Work involved by theANOfd ,f' UPPER P ermMANHOLE REFERENCE it is for one hundred dollars ($100)or less.) LOCALITY �� t. - ^ LOWER I certifythat In e' performance of the work for which this CROSST NEAREST TYPE OF CONNECTI J LENGTH FROM thp CROSS I ,..E--•.,.,, Y. CURB P.L. .L�TO P L. permit is issued, i shall not employ any person in any manner SO aS 10 become subject to the Workers'Compensation Laws. OWNER 'frtdm�••,•�s�",»_- ( " „'mss✓ ,.r CO.IMP.NO. –Tlob N°. MAIL TRUNK PERMIT NO. ROAD PERMIT NO.. Date Applicant, „ ADDRESS k A d f _ RECORD.INSTR.NO. DATE: NOTICE TO APPLICANTS If, after making this Certificate of city �" TEL No _ =MENT. Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. corply with such provisions or this permit shall be deemed HwY OR ST.WIDENING n revoked. BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO. I hereby affirm that 1 am licensed under provisions of Chapter SIZE OF LOT NOW ON LOTUSE OF 9 (commencing with Section 7000) of Division 3 of the Busi- BUIL.DINS /�� CHARGES ness and Professions Code, and my license is in full force and qlr effect. CONTRACTOR CONNECTION CHARGE FEE >- License Numbe l.ic.C1011-7 REIMBURSEMENT FEE CL ADDRESS O �� DISTRICT NO. GROUP MAP PROCESSED BY ContraCtO Date BS�q u CITY C" TEL.NO. BK PG Z STATE fo. sr ,r-�`y ,.:- LIC. ` O ❑ I am exempt under Sec, of the L.A.Co. LICENSE NO. class _ Plumbing Code and/or Sec._ of the NO. CIESCPIPTidN OF RK FEE FINAL H7USE.SEWER CONNECTING 70 DATE HOUPUBLSE SEWER ` VALIDATION a B. 6 P. Code for the following reason_ ) ! tis SEPTIC TANK,SEEPAGE PIT OR FINAL t 4 PITS AND/OR DRAiNFIELD Date HOUSE SEWER CONNECTING TO BY r s t k,v PRiVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL OR QWNER-BUILDER DECLARATION WORK rO HOUSE SEWER OVERFLOW SEEPAGE PIT DRAINFIELD I hereby affirm that I am exempt from the Contractors License EXTN CESSPOOL,DRYWELL,MANHOLE •�,� Law for the following reason (Secton 7031..5, Buisness and Pro- AL'.ER,REPAIR OR ABANDON HOUSE fesslons Code): SEWER OR DISPOSAL SYSTEM [� I,as owner of the property,or my employees with wages as , their sole compensation, will do the work and the structure KA 41' is not intended or offered for sale (Section 7044, Business � 1�Go13 and Professions Code). OWNER'S Permit `P I,as owner of the property,am exclusively contracfiing with AUTHORIZATION TOTAL FEE 56 TOTAL L . 50 licensed contractors to construct the project (Section 7044, HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO g¢�'x"q{ r-7 C;"j Business and Professions Code). CONNECT THE ABOVE.DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.. b•9'4Gl-t% a`.c• ••{. CONSTRUCTION LENDING AGENCY � h SIGNED THIS 14 =01 I hereby affirm that there is a construction lending agency _ `' i� L for the performance of the work for which this permit is OWNER DAY OF OWNERS AGENT issued (Sec. 3097, Civ. C.). � � t? ADDRESS d Lender's Name— _ _ ' Lender's Address__ 81 AM 1,-11 I certify thatA have read this application and state that the above infor ationjs-C' sect. I agree to comply with all County ordinance cpnd,�ate aws regulating Plumbing and Sewers, and her*> ,,thoriz rep�rasentatives of this County to enter upon thg -1,e-me tion property for inspection purposes. A r & r4Ci ure of ermittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE r WORKERS'COMPENSATION DECLARATION gf ` J I hereby affirm that I have a certificate of consent to self / tom % ry insure1w,a certificate of Workers'Compensation Insurance, or �eAea2o p licy iedcopythere c. 3800, .) CEBQB(REV.BBi) APPLICATION FOR PERMIT ,policy 40 1- 4T 0./a e �mF ,,. �❑ Certified copy is hereby furnis �,c L f. j 05 SEWER - SEWAGE DISPOSAL Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY �opartmep� Dote� _ pplicant FOR APPLICA#T TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING �ry ,� COMPENSATION INSURANCE ADDRESS °` STATION1 ( "`7 i�' DEPTH (This section need not be Completed if the work involved by the MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) LOCALITY LOWER ST I certify that in the performance of the work for which this CROSS Sr. TYPE OF CONNECTION LENGTH FROM permit is issued: I shall not employ any person in any manner Y CURB P. . M.L.To P.L. so as to become subject to the Workers'Compensation Laws. /, P.C.No. OWNER 1iYJ 0 T CO.IMP.NO. LOB NO. MAIL TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL NO. AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DA?E Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. comply with such provisions or this permit shall be deemed HWY.OR ST.WIDENING revoked. BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION No OF BLDGS. PERMIT NO SIZE OF LOT NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter USE OF 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES ness and Professions Code, and my license is in full force and effect. a rte' CONTRACTOR 0 L CONNECTION CHARGE FEE � License Numbtl LIC. lass ADDRESS REIMBURSEMENT FEE O Contractor - e DISTRICT NO. ROUP MAP PROCE SED B V L` �' CITY TEL NO- BK FG Z STATE LIC. j, `��`"�� O ❑ I am exempt under Sec. of the L.A.Co. LICENSE No CLASS ✓f '�.., V NO. DESCRIPTION OF WORK FEE Plumbing Code and/or Sec. of the FINAL " 4'` VAL DATION a HOUSE SEWER CONNECTING TO DATE y B. & P. Code for the following reason PUBLIC SEWER SEPTIC TANK SEEPAGE PIT OR FINAL Z PITS AND/OR DRAINFIELD ,�" Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR (' OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINHELD r ^]`� f �� .� .y I hereby affirm that I am exempt from the Contractor's LICP.nSe EXiN.,CESSPOOL,DRYWELL,MANHOLE , {� �u��'� Law for the following reason (Secton 7031,5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE a fessions Code): SEWER OR DISPOSAL SYSTEM 33 ❑ I, as owner of the property,or my employees with wages as +-, 50 their sole compensation, will do the work and the structure O TTL 27 °" is not intended or offered for sale (Section 7044, Business L L) and Professions Code). OWNERS Permit $ / ..,s CHECK 27.__ ❑ 1, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE licensed contractors Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER, CONSTRUCTION LENDING AGENCY tl'1-- 5 Ce° I hereby affirm that there is a construction lending agency SIGNED THIS-DAY OF 19_ 010 for the performance of the work for which this permit is OWNER oRt amu" x3 % `:�c issued (Sec. 3097, Civ. C.). OWNERS AGENT .„t 2 x AMI1 a ADDRESS Lender's Name Lender's Address 1 certify that 1-have read this application and state that the above infor ation is correct. I agree to comply with all County ordinance grad State„l.a. s regulating Plumbing and Sewers, and her ;y auiie r resentatives of this County to enter Upon th"g- bo e-Ment" ned property for inspection purposes. 007 Signature o mittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE