HomeMy Public PortalAbout6025 CAMELLIA AVE_Sewer__ WORKERS'COMPENSATION DEaARATKNI
I hereby affirm that I have a certificate of Consent to self
Insure, or a certificate of Workers'trompinsation Insurance, or
Med Copy thereof
a ` of.
3800 c ) 0-W= """ APPI.KATION FOR PERMIT
No.—Company ��� J��
Fj
CCertified copy Is hereby fumishecL SEWER SEWAGE DISPOSAL�,.
erttfied copy is filed with the ty bul I on COUNTY OF LOS ANGELES - 46ILDING AN6 iAiTY
cleparhTown�-t
DateApplkantpe, POR APPLIECANT TO FILL IN CONNECTION DATA
CERTIFICATE OFFROMWC;W
COAAPEN.SA INSURANCE AADDr��s / f STATION Degrii
(This section need not be completed if the work Involved by the yyy+{p� UPS
permit Is for on* hundred dbllors (=160)or les ) LocALMY
I certify that In the performance of the work for which this �. TYPE OF CCt*&rTK)N �TM�
permit Is Issued, I shall not employ any person In any mariner CURB P.L AlL TO P.L
so as to become subject to the Workers'Compensatioh Laws. ave co.LW.No. "NO.
. MAL TRUW PERWT Na ROAD PERWT NO.
Date Applicant
NOTICE TO' APPLICANT: If, after making this Certtfitafe of �y Tai No. ,. �VIT WAHR awn RECORD.*CR NO. DATE
Exemptlon, you should "become subject to the Workers'
Compensation provislont of the Labor code, you must fbrthwtifa des�prloN for No HWY.oa>A.WDBi NO
comply with such provtslons.or this,permit shall be deemed
revoked, ROac TRACT STATE
LKZNSED CONTRACTORS DECLWT40N NO.OF EIDO& PEAT NO.
JIM Or LOT NOW ON LOT
I hereby affirm that f-am licensed underprovlalOn@ of Chapter
LM Of
9 (commencing with Section 7000) of DIY(slon 3 of the Bull- eJLDIrNGs CHARaa
nese and Profeesions Code, and my license is In full force and ;
effect. OWMACroa coNm Cr10N aiAax m 8
Uceme Number C.G ADo !!5 r$ y
Contractor Dale J DWWCT NO. GROUP MAP �BY �¢
. CTT1' TB.NO. � �
❑ i am exempt under Sec of the L.A.Co. �j�M NO, CLASS
Plumbing Code and/or Sec. of the NO.
DBM PiION � I �q
HOLM amt VALIDATION Z
B. b P. Code for the following recoon
PUBLIC MWERWER O NNIECT i TO DATE (� M 110 ZZZ
PTTS MT � FP1A1 — -
Date_ HOU!3146!COP!!CTIQ TO BY
PRIVATF DL9K11W r,'XTF- 4�lj i T
Signature OWNER-BUILDER DECLARAMN WO TO HOliseCONNECT MSEWBt OR ,
I hereby affirm that I am exempt from the Cootrocfors Ucense ExrN. MMiiOLE
Law for the following reason (Secton 7031.5, Bulsnes and Pro- AL ROHM OR HOUR iQ
fesslorx Code): OR DMIFOSAL SYMPA
i
❑ I,as owner of the property,or my employees with wages as ANT,
their sole compensation,will do the work and the structure
Is not Intended or offered for sale (Section 7044, NnIness i 77 7 .
and Professions Code). OVYNEn Permit 3 1 ITEMS
❑ 1,as owner Qf the property,am exclusively Contracting with AUTHORIZATION LTOTAL FEE
licensed controctors to constructAMfD the project (Section 70", 1 HAVE AT TM tATE A CONTRACT WTTH THE HeRIDN NTO TOTAL 34-50
Bushes and Prof6W,onsCode). CONNELT TI"!'ADOVE DEBOMED DQUIN 3 DVAUM(�TO THE"AJC Sw6L DECK
affirm
LENDING AGENCY
•
I hereby arm that there Is a constructlon IendIN agency WW THIS DA OF 19 , C - .00
for the performance of the work for which this permit Is Owr�OR
A( 1T
Issued (sec. 3097, Clv. G OWNERS
). AooRrss '
Lender's Name 001DD–W01 4/12/911
Lenders Address 0064 1 AM 10 71
I certify that I have read this application and state that the
above Informatlon Is correct. I agree to comply with all County
ordinances and State laws regukrting Plumbing and-Sewers,
and thorl representatives of this County to enter
upon t ntl or Irrpsctlon purposes.
9W11INV fs M9 DMUMATORY WKWAG4