HomeMy Public PortalAbout5703 CAMELLIA AVE_Sewer__ WORKERS'COMPENSATION DECLARATION Tr ,
I hereby affirm that I hove a certificate of consent to self
Insure, or a certificate of Workers'Compensation Insurance or 76A642D
a certified ropy thereof (Sec.'38001, La,� t`�'.8'8
1) APPY'JcR ION AOR PERMIT
Poll jJo nv \.• -
Ifl ca Is fumished. SEWER - SEWAGE DISPOSAL
od copy I I Ith the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
Docant FOR APPLICANT TQ-FILL IN CONNECTION DATA
CERTIF TE OF D EhkPTION FROM WORKERS' eusarta 7 D
COMPENSATION INSURANCE
(This section need not be completed If the work Involved by the W -KXE RH•ERe•1Cl..'�41 f p, U.
permit Is for one hundred dollars ($100)or less.) LOCAlrtt ,Zff
TYPE OF FROM
I tartly' that In the performance of the work for which this �ST. T Y. 047TH P.L
'7 � .CURD P.L M.L.TO P.L �
permit Is Issued, I shall not employ any person In any mannan
so as to become subject to the Workers Compensation Laws. P'��' O
I Pe owrst CO.W.P.NO. Joe No. 0
TkLM PERWT NO, ROAD PM WT NO. -S'
eQY
Dat _Applicant l ca nt ADDRESS O
NOTICE TO APPLICANT: If, after making this 'Certificate of Qn TEL No. AH:iDAvrr wAtvet EASEMENT RECORD.NSTIL NO. DATE
Exemptlon, you should become subject to the Workers' LU
Compersatlon provisions of the Labor ccdo,you must forthwith DESCRIPTION LOT NO. Ifiyy OR ST.�ypgspp IL
comply with such provisions or this permit shall be deemed to
revoked. ISLOCx TRACT _ STATE BdCROACFNIB•fT Z .
LICENSED CONTRACTORS DECLARATIONNO.OF XDGe PERMrT
SEE Or Lor NOW ON LOT
I hereby affirm that I ath licensed under provisions of Chaptpr USE OF
9 (commencing with Section 7000) of Division 3 of the I BUSDINOS CHARC3�5
ness'and Profe"Lo Code, nd my lice full for and '
effect. alp
License N LIc.CI �DpgS FEE
Contract
Data DaTRICr No. GROUP MAPAP ay
CITY. ND. BK PO
❑
lam exempt under of a LA Co. ULA 1M NO 0&#A S 6V
to
Plumbing Code and/or Sec. of the �' I PVtDN tf WORK RNAL -01
HOUSE SEWeR CCt*&-CT1NG TO DATE VALIDATION
B. & P. Code for the following reason PUBLIC
T PrL OR FSNAl
Dates PITS ArD/OR DRAIII B 6Y
FiOJW SFATR CONNKTI NO TO .
Signature COMKT ADDrrlowl .OR ,
OWNER-BUILDER DECLARATION WORK To HOLM SEWER
I hereby affirm that I am exempt from the Contractors License EXTN
Low for the following reason (Secton 7031.5, Bulsness and Pro- KTat RIYAW OR AAAN ON HOLM
fesslons Code): EM�t OR DidP064L SYSTEM
Q I,as owner of the property,or my employees with wages os ;R 3 1 a 4 A
+teir sole compensation, will do the work and the structure
Is not Intended or offered for sale (Section 7044, Business 0
and professions Code). OWNER'S Permit $ Q
❑ 1,as owner of the property,am exclusively contracting with AUTHORIZATION TOT F 12 0 -,2 7'5 0
licensed contractors to construct the project (Section 7044, I HAVE AT THR DATE A TO J
Business and Profesilons Code}. CONNECT THE ABOVE DESCRI ED NG T -.27.5 0 H
CONSTRUCTION LENDING AGENCY
I I hereby affirm that 4here Is a construction lending ogency SAC44EDTNIS 9— , 0 6 2 47 8 3
for the performance of the work for which this permit Is aNER oR'
owr8rs AQEt•Q
Issued (Set. 3097, Civ. C- .
ADDRESS
Lender's Name
Lenders Address
I certify that I have rood this appllcatlon a to that the
above Informatlo is correct. I to compI all County
ordinances an tate laws sat um ng
and her orize ropr nta es of Co to enter
upon the ention f rposea
S I g re of ttee tial FSVWM FOR DtTLANATOttY LAN UAG14
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