HomeMy Public PortalAbout6008 CAMELLIA AVE_Sewer__ '(ACRKERS' COMPENSATION DECLARATION
I hereby affirm chat 1 have a certificate of consent to self 200061 OPvItSBB
insure, or a certificate of Workers' Compensation Insurance, or 7BA642D
a certified copy thereof (Sec. 3800, Lab C. APPLICATION FOR PERMIT
Policy No. Company'
I ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
❑ Certified copy is filed with the county building Inspection
COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BLnLDINo
COMPENSATION INSURANCE sTATIorJ DEPTH
(This section need not be completed If the work involved by the CHOLE Rte UPPER
permit is for one hundred dollars ($100)or less,) LOCALITY
rtEAarBT TYPE of CONNECT ION TFROM
I cC M L certify that in the performance of the work for which this cFtose Br. C} Y uae P I M L TO
P L
permit Is issyed,1 shall not employ any person In any manner
LEGAL PC NO
so as ib become subject to the Worker Cornpensaflon Laws. DE8CAIPTION LOT NO. CO IMP NO xx NO
Date Applfcant tLoCx TTHACT TRL"PERMIT NO ROAD PERMIT NO
NOTICE TO APPLICANT: If, after making this Certificate of 3 PAGE 0 PAFCQ KFFIDAVIT WAIVER EASEMENT RtcoRD 111-ITRFtp DATE
a
Exemption, you should becgme subject to the Workers' rsO.OFLDGs
Compensation provisions of the Labor code, you must forthwith SIZE OF LOT New ON LgT HWV COST WIDENING
comply with such provisions or this permit shall be deemed USE
revoked.
revoked. BE ILDI Mc1B STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION PEWAU No
I hereby affirm that I amlicensed urider pp++ovlsioas of Chapter OWNER — �� �ti
9 (commencing with Section 7000) of DIvlslon 3 of the Busi- M'0RE98 t C1H.AJIGAS
ness and Professions Code, and my license is In full fores and
effect. CITY TEL NO. Z Z g CONNEcnoN CHARGE FEE
License Number Lit.Class REIMBURSEMENT FEE
COHTRACTOEt
Contractor Date txsTR RCT tto GROUP MAP ev
ADD
El am exempt under SecCITY. of the L.A. Co. ITY S 0 6
TEL No. ,
Plumbing Code and/or Sec. of!the STATE UC VALIDAT N Z
WCENBE NO. CLW DATE
B. 8 P.'Code for the following reason no. DESCRFTK N OF WOItK FEIE
HOUSE SEWER CONNECTING TO FINAL t
Date PLT6LIC SEWER BY
DTIC TANK SEEP PIT OR ,
Signature PITS AND OR DRVNF y
OWNER-6411-bER DECLARATION ]ov SEWER CONNECTING To , Z
PRIVA
1 hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONA1 BLDG OR
Law for the following reason (Secton 7031.5, Buisness and Pro, WORK TO HOUSE SEWER
ovERFPAGE PIT.DRAINFIFLD 5
feuions Code): L SEEDRYWELL MANHOLE
I,at owner of the property, or my employees with wages as REPAIR OR ABANDON HOUSEf
•T•T OR DISPOSAL SYSTEM AC
their sole compensation, will do the work and the structure cc
is not intended or offered for sale (Secflon 704", Business 55.3-5
and Professions Code).
1 ITEM
❑ I, as owner of the property, am exclusively contracting with
licensed cantractors to construct the project (Section 704", OWNERS Permit $ TOTAL 55 . 35
Business and Professions Code). AUTHORIZATION TOTAL FEt CASH 7,5._7
CONSTRUCTION LENDING AGENCY I HAVE AT THr5 DATE A CONTRACT WITH THE KEREIN NAMED CON RAc To Pilo.1 hereby affirm that there is a construction lending agency cONNFCT D-1 ABOVE DESCRIBED EXISTING DWELLING TO TIF PUISIIC SEWER A4� .00
for the performance of the work for which this permit is GWa
issued(Sec. 3097, Civ. C.). SIGNIFD THIS DAY OF 19_
OWNER OR i
Lender's Name OWNERS AGENT � 1 11/23// 4
Lender's Address ADorzFss M�6 1 AM q;4{I
1 certify that I have read this application and state that the
above Information is correct. I agree to comply with all County
ordinances and Slate laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upon the above-menfionpd property for Inspection Vi-posers.
� kR!� ��n a it/
1
Ignaiure of Perm ee DateI EEE REVME FOR EXPUUVATORY LAIiGUAGE