HomeMy Public PortalAbout5208 CAMELLIA AVE_Sewer__ WORKERS' COMPENSATION DECLARATION {�
I hereby aff)rm tlirot I hove a certificate of consent to self 7BA04T DPW BM u
insure, or-9 certificate of Workers' Cornpensatioh Insurance, or
a„cer-Sfi'ed copy thereof (Ser. 3800, Lab C.) - APPLICATION FOR PERMIT
Policy No. Company
❑ Certified copy is hereby furnished. SEWER • SEWAGE DISPOSAL
❑ Certified copy is filed with the county building inspedion COUN1Y OF LOS ANGELES BUILDING AND SAFETY
department.
Date Applicant FOR APPLICANT TO FILL IN .CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' Bl1I DirlCi
COMPENSATION INSURANCE Z,O STATION DEPTH
(This section need not be completed if the work involved by the MA*TOLE REFEkENoCE UPPER
permit Is for one hundred dollars ($100)or less.) TYPE LA LOCALITY
CONNECTION
I certify that in the performance of the work for which this Ncripgggr. RNA
� ENGmf�
Permit is issued, 1 shall not employ any person in any manner LEGAY CORS P L ML TO P L
so as to become subject to the Workers'Compensation Laws, DEBP TON Nco IALP No toe NOO. P C NO
Date Applicant BLopc TRACT TKrW PERMIT NO ROAD PERMIT NO
NOTICE TO APPLICANT: If, offer making this Certificate of AMAP-BOOK PA13E P Ip�vAFFIT wuvER EASEMENT REcoao iHSTu NO DATE
Exemption, you should become subject to the Workers' NO OF OLDGS
Compensation provisions of the Lqbor code,you must forthwith SIZE OF LOT Now ON LOT HWY C.R ST WIDENING
comply with such provisions or this permit shall be deemed USE OF ,
revoked. EIUILDINOB STATE ANT
LICENSED CONTRACTORS DECLARATION PEWM r4o
1 hereby affirm that 1 am I1Censed under provisions of Chapter
9. (commencing with Secifon 7000) of Division 3 of the Bust- A�DOREe ��Ni- atA�caS
near and Professions bode, and my license it in full force and
effect. art6TTYNo. Cctra•E ",l a-A 1GI FEE
License Number Lic.Class,
WIMALR9MEN1 FEE
CONTRACTOR
Contractor Date MTRICT GROUP MAP er
ADDRE9S D� eX PG
S.
❑ 1 am exempt under Sec. of the L.A.Co. TEL No, � Lp
Pfumbing Code and/or Set. of the STATE uc. 7NAVALIDATION z
LICENSE NO. CLASS DATE
B. 8 P- Code for the following reason NO. DITcf>pnoH OF WORE( FEE p
t HOUSE SEWER CONNECTING TO ,s n eFnlA1
Data Pm c SEWER f-srr
SEPTIC TANK SEEPAGE PrT Oft
Signature PITS ANO OR DRAINF*iD
OWNER-BUILDER DECLARATION HOUSE SEWER C NI ECTRJG TO ,
PRNA D5YSTLM
I hereby affirm that I am exempt from rhe Contractor's License CcxrrECT AWFTK)NAL BLDG OR
Law for the following reason (Secton 7031.5, BUisness and Pro- WoaK TO HOUSE SE)WER 10
fessions Code): OVERFLOW SEEPAGE PIT.DRAiWiELD
ExTN.CESSPOOL.DRYWELL MAN410LE
® I,as owner of the property, ALTER.REPAIR C ABANDON SYSTEM SF
ACCT.T
p pe ty, or my employes with Wages03 SEWER pR ISPOSJLL SYSTEM
their sole compensation, will do the work and the structure73.50
is not Intended or offered for sale (Section 7044, Business
and Psofesslons Code). 1 ITM
❑ I, ds owner of the property, am exclusively contracting wrth Permit $ TOTAL 73 -50
licensed contractors to construct the project (Section 71}44, OWNER'S
l Business and Professions Code). AUTHORIZATION I TOTAL FEE DECK 73.50
' CONSTRUCTION LENDING AGENCY I I-LAVE AT THIS DATE A CONTRACT WITH THE hERELN NAMED CONTRACTOR Tp , .00I I hereby affirm that there is a Construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER
for the performance of the Work for which this permit is
issued(Sec. 3097, Cv. C.). SIGNED THIS DAY OF .19—
t1kR OR
Lender's Name O RS AGENT 0000–"l 4/ 5/96
Lender's Address ADORESS5724 1 AM 9:58
I certLfy that I have read this application and state that the
above Information is correct. I agree to comply with all County
ordindacea and State I regulating Plumbing and Sewers,
and hereby authors representatives of this County to enter
upon the above- atloned prop for Inspection purposes.
Sig lire of Permittee pate SEE REVEIKE FOR EXPLANATORY LANGUAGE