HomeMy Public PortalAbout6044 CAMELLIA AVE_Sewer__ WQRKERS'COMPENSATION DECLARATION
I hereby affirm that 7 have a certificate of consent to self
Insure,pc a certificate of Workers'CoTnpensatlon Insurance, or 7aAb4
acertified copy thereof (sec . 3800, Lab,C.) CE"(Rr"'"I) APPLICATION FOR PERMIT
-�ollcy t1o. Company ms
'❑ c�ttfied copy is hereby furnished. SEWER - SEWAGE DISPOSAL
❑ Ce Nfled copy Is filed with the county building-Inspection COUNTY OF IROS ANGELES BUILDING AND SAFETY
department.
Date_Applicant FOR APPLICANT TO FILL IN CONNECTION DAT
CERTIFICATE OF EXEMPT" FROM WORKERS' MUMJYNG
COlV1PENSATION INSURANCE STATION DEPTH
(This section need not be completed if the work Involved by the UPPER
LOCALITY ^""�"'�E Rte
permit Is for.one hundred dollar (j100)or less.)
I certifythat In the anance of the tr
NE TYPE OF tEt G FROM
perfo Work for which this CRS�,
permit Is Issued, I shall not employ any person In any manner Y. a�Rn P.L AIL To P.�-
'so as'to become subject to the Workers'Compensation Laws. Oyti,p� , CO.LMP NO. jos NNOO.
AWL
Date—
C rRLR1C t$tAur r/0. Raw P8tMrr No. .
Date Applicant ADDRESS ITS
NOTICE TO. APPLICANT: If, after making this Certificate of Cr, S TTi No A+�A`TT WAS EA- T RECORD.INSTR.NO. DATE
ct
Exemption, you sbould become subjeto the Workers'
Compensation proylslons of the Labor code, you must forthwith 21=t7Opt IAT NO. ELIO I,'J31z, KWY OR ST WMeM,p
comply with such provlalans or this permit shall be deemed
revoked. - IkOCK TRACT STATE Bi�oA+C}V�VE3JT
LICENSED CONTRACTORS DFCZARA710N NO.OF Foca PST
S zF o(-LOT >K NOW ON tOT
Ihereby affirm that I am licensed under provisions of Chapter U$EOF .
0 (corr)mencing with Section 7000) of Division 3 o'f the Busl- Du LDLtM aiARc s
noes and Professions Code, and my license Is In full force and
effect. CONTRACTOR COt#ECTOP4 CHARGE FEE
License Number Llc.Class ADDRESS R21VBURSEMENT FEE 0
Contractor Date DMrRJCT NO. MAP PROCESS BY V
El .Ltqew�ITY TEL.NO. a.Aas ,(� � - /3 q o
SLATE LIC
I am exempt under Sec. of the LA Co.
NO. DESCRIPTION OF WORK FEE
Plumbing Code and/or Sec. of the DATE V L ATION a
PL�SEWER CONfCTWO TO DATE 1/
B. b P. Code for the following mason N►
I"/&
SEEPAGE ARA=I PTI OR TINA.
• PETS M•D/OR DR. D
Date HOUSE SEWER OONNECTM TO BY
Pi�NATt
Signature `CDKtKCT DITYONAl OR
OWNER-BUILDER DECLARATION F�IOUSE ;y
I hereby affirm that I am exempt from the Contractors License � M KXE 10
Low for the following reason (Secton 7031.5, Bulsness and Pro- REPAIR OR ABANDON HOUSE y
'fesslons Code): MOR DMPOSAL FATEM AA 3 1-■T
❑ I,as dwner of the property,or my employees with wages as 3307 27.50
their sola compensation, will do the work arld the structure 1 1
Is not Intended offered or oered for sale (Section 7044, Business Permit f Q O T F - - �
erty
and Proferslons Code). OWNER'S
owner of the prop ,am exclusively contracting with AUTHORIZATION TOTAL FEE
Contractors to Construct the project (Section 7044, I HAVE AT THRs DATE A CQNTRACT WITH THE NAMED COtMACTOR TO C CK 27■50
Buslnees and Professions Code). CONNECT THE ABOVE EXMnNG DWELLWG TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY sG Eb
��S OF .00
I hereby affirm that there Is a construc►lon lending agencysfor the performance of the work for which this permit Is O
Issued (Sec 3097, Clv. C). L 0000r-0001
ADDRESS, 10/ 5/89
Lenders Nom•
6076 1 AM11=40
Lender's Address
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 entet
upon the above-mentioned property for Inspection purposes.
I
r
Ig date SU KVR"FOR DULANATORY L.AWWAGE