HomeMy Public PortalAbout6030 CAMELLIA AVE_Sewer__ WORKERS' COMPENSATION DECLARATION {�
200067 DPW BBB
I hereby oArm that I have a certificate of consent to self u
insure, or a_ccrtificate of Workers'Compensation Insurance, or 7BAC42D
00
a certlfied copy thereof (Sec. 38 , L C APPLICATION FOR PERMIT
Policy No. Company SEWER - SEWAGE DISPOSAL
El Certified copy Is hereby furnished.
❑ Certified copy Is filed with the county building inspection COUNTY OF LOS ANGELES -BUIL-pINr,AND SAFETY
departure t.
Dated �-L-2tpplIca nt \o � FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' FKI-
COMPENSATION INSURANCE STATION OfPTr(This.section need nor be completed if the work Involved by the MANHCXE REFUMNCEUPPER
permit is for one hundred dollars (5100)or less.)I certify that In the performance of the work for which this Y TYPE OF CON rECnON LENGTH FROM
permit is issued, 1 shall not employ any person In any manner CUR's P L M L To P L
so os to becomd subiect to the Workers' Compenadtlon Laws. LOT No. cd MP NO 10e r pTRACT TRUW PERMIT NO ROAD PERMIT NO
Date Applicant-
NOTICE TO APPLICANT: If, after making this Certificate of PAGE P AFFID vrt wArvER EASEMCTJT RECORD IIVSTR NO DATE
AFICEL
Exemption, you should become subject to the Workers' No OF BUD-G&
Compensation provisions of,the Labor code, you must forthwith SUI OF LOT NOW ON LOT.' HWY OR ST WIDEN LNG
comply with such provisions or this permit shall be deemed UBEOF
revoked. BUILDiNa8 STATE ENCROACHMENT
LICENSa D CONTRACTQRS DECLARATION PERWT No
I hereby affirm that I am licensed under provisions of Chapter OWNER
9 (commencing with Section 7000) of Division 3 of the Busl- LADDREW
r Z pFs
ness and Profeulons Code, and mfr license is in full force and �7
effect. CrrY TEL NO. / U CON-NEC
CT014 CRAR'f FEELicense Number 461103 Lic.Class L-'J& S RE FEE
Contractor W7 iTf Date
p a CONTRACTOR DISTRICT NO GROUMAP P PROCESSED tSY
7�Z1`l 2�_
ADORSB Bx PG
❑ 1 am exempt under Sec. :of the L.A.Co. CFY TEL No
Plumbing Code and/or Sec. of the 8TL ICEPME At*O Q-L A L DAR VALIDATION
B. B,P. Code for the following reason No. Deect�no►+OFwowc FEE `Z Z
O
HOUSE SEWER CC#4NEL?iNG TO HNAL
Date PUBLIC SEWER BY
TANK,SEEPAGE Pit OR
Signature PITS AND OR DRAINFLE D
OWNER-BUILDER DECLARATION AOUSE SEWER CCt**(TTTING TO
PRNA r
I hereby affirm that I am exempt from the Contractor's License CONr•ECT ADDITIONAL BLDG OR
Law for the following reason (Secton 7031.5, Bulsness and Pro- WORx TO HOOSE SEWER
feulOns Code): OVERFLOW SEEPAGE PIT.DRAINFIELD {.-.
ExTN CESSPOOL.DRYWEU MANE-IOIE •Iu .
❑ I,d3 owner of the r0 ALTER.REPA'R OR ASAr•DON HOUSE
property, or o the work
an with wages as SFAU OR DL3POSAL SYSTEM 66.5]
their sole compensation, will do the work and the structure
Is riot intended or offered for sale (Section 704 , Business f ZTGI�
and Professions Code).
❑ 1, as owner of the property, am exclusively contracting with OWNERS Permit f S 1 FjTk 66 - 53
licensed contractors to construct the protect (Section 704 ,
Business and Professions Code). AUTHORIZATION TOTAL FIEE 4-1 A
CONSTRUCTION LENDING AGENCY I HAVE AT Trus DATE A CONTRACT WITH THE HEREIN D CONTRACTOc TO
1 hereby affirm that there is a construction lending agency CONNECT THt ABOVE DESCRIBED ExrSTWG DWELLING TO THE PLISLFC SEWER
for the performance of the work for which this permit is
issued (Sec. 3097, Crv.C.). SIGNED THIS DAY OF 19_
Lendper's Name NER X0
AGENT C —XJ13i 7/7`j���`
-15
Lender's Address ADORess I AM 2:,
I certify that I have read this application and state that the
above Information Is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes.
Signature of Pe mittee Date SH REVERE!FOR EXPLANATORY LANGUAGE