HomeMy Public PortalAbout6031 CAMELLIA AVE_Sewer__ WORKERS'COMPENSATION DEQARAT}ON
I hereby afflrrn that I have a certificate of consent to MFF
Insure, of a certificate of Workers'Compensation In urgrice, or M4420a certified copy thereof (Sec. MM, Lab c) '�-0°°`°P' "" APPLICATION FOR PERMIT.
Policy No._Compgny
� ttfl,d copy is h1Teby�,„r,l, SEWER - SEWAGE-DISPOSAL ,
❑ certified copy Is fl led with buI p I on ' COUNTY OF LOS ANGELES BUILDIN¢AND SAFETY
departs»ni.
d
App IIca rit FOR APPLICANT TO FILL IN CONNECTION DATA
CE$M tCATE OF
COMPENSATION INSURANCE A�iSorr>3s / STATION DEPTH
(This section need not be completed if the worn involved by the MANi0110"504a
perrntt Is for one hundred dollars ($1M.)a len. NEAREST} LoGurrY -*
PROM
I certtfy thatm
In the performance of the work.for which this Q ISH
pwm" Is Issued, i shall not emppIloy any person In any manner Y sate P.L rrtL ToP.L
to as to become subject to the Workeri Compensgtlon Laws. a 's, pp.LW_NO. X.
TRUN(PERJ WT NO. ROAD PERWT NO.
Date. Appllgant
NOTICE TO APPLICANT: 1f, after rnaklrig thlr Certiffcote ofAR3DAVTT waer vEAsEP04Nr RECORD.INSnt NO. DAA
Exemption, you should became sublect to the Workers Te
Compensation provlslons of tfro Labor code, you must forthwith DEqmzFtON. LOT NG. FWY.OR ST.WtD011146 .
comply with such provisions or this permit shall be deemed
revoked, ti100( TRACT STATE e�rYMBdT
?Bk
LICENSED QONTRACTORS DfCl/1RATiQNNO,Cr BDOI NO.SLZE OF LOT NOW ON
LOT
I hereby affirm that I-am lleinsed under provisions of Chapter
CIR
4 (commencing with Section 7000) of Div(sion 3 of the Sus1- KM
near and Professions Code,arid my license Is In full force and
effect. f coNTRAcroa CON ECrroN 9-V"�.
•Llcen"Nu klc.'Class `/+y ADDRESSr/-
Con tracto � 4��7r Dat.&n Q':7cm NO. DMTRICTNO. GROUP MAr Tc
/�� KK PG
❑ l am exempt urrder Sec 4 of the l_A..Co. ATE NO. CIASS 5 0
Plumbing Code and/or5ec., of the �. I FINALV
I-oua SPOM oorricnrra,TO DATE VALID F N
B. & P;Code for the following reoeon PLOX to
. RT ORRNAL
rTTs
RIA DRAR4'0-D BY
HDU ft1V6!OONNECTNG TO
S4gnatureNITIVA
CONNECT ADDMONA1 BLDG.OR
OWNER-BUILDER DECLA AT1ON ;Aa7H SEWER
I hereby affirm that I am exempt frorri the Contractor's License ocrN MANFK E
Law for the following reason (Sectpn 7031.+5, Bulsrreas qnd Pro- SYSTEM FPOUSE 10.
fesslgns radar 'ACC t
❑ 1,as owner of the property,or my employees with wages as
their sole compensation, will do the work and the structure 3M7 34.50
Is not Int+rAi!d or offered for sale (Settion 7044, Buslne" Perrriit =
arrd Professlons Code),
OWNER'S
❑1;w owner ofthe property,am pxcluslvely contracting with AUTpORIZATION TOTAL FEF TOTAL
licensed corift-o tors to construct tlje Project (Section 7044, I ww,v[ AT Y!!ts DATE A ppNrRAc r wrTfi n# 34 �
�knlness and ProfpWons Cbde). . CorrecT T}!ABOVE D�GRf�oasrtra Dvr�LrraF +arc sewer - ro
MCK 34.50
CONSTRLKTFON LENDING AGENCY ^
I hereby affirm that there 14 g construction lendlrlp agency SIC�NM THIS DAY 19
for the performance of the work for which this persalt Is OW43t CA
OWrBts^7r
tasued.(Se 3097, civ.c} A
Lendetrs Name
0000—Ml w4/i�i0
Lenders Address � � � 067 Ati1Q:
I certify that I have read this application and state that the
above InfprmWlon Is correct. I agreeMof
mply with all County
ordinances and State laws regulatlumbing and•Sewers,
and h authorize repre•en this County to enter .
upon entloned for Inspection purposes.
11i ure 6T1`1__ ttee Date am R81IRffi POR C04 ANATOWY LAM"AW