HomeMy Public PortalAbout6048 CAMELLIA AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
I hergby 4firrrT that' I have a certtflcote of consent to self
insure,pra ctis of Workers' ns
Compeatbn Insrorxa
ue,
acrtffi �w APPLICATION. FOR PERMIT
a aed copy py thereof
c.of(se3800, Lab C.) -
P*ollcy No.T C yany
furnished.
ished. SEINER - SEWAGE DISPOSAL
❑ ed copy Is hereby um ,
❑ ed copy'Is filed with the county building Inspedlon COUNTY OF LOS ANGELES BUILDING AND SAFETY
department. �J
Date Applicant FOR APPLICANT TO FILL IN PPI CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' EUSD1No1�1C�
COMPU4S4rION-INSURANCE ADO.W L L C— STATION 4�rH
(This sedion need not be completed if the work Involved by the Lin MM➢ptJ a�m�
UFA6r
permit Is for one hundred dollars(;100)or less.)
I certify that in the performance of the work for=whkh this ar: AkI&ILDI Y. OF CURB P.L rTYPE CW4ECTION LTTOO�
permit is issued, I shall not employ any persoh in any manner P�No
so as to bicome subled to the Werken'Compensation Laws. OWNER (� CO,yam.N NO.
to �G TRUW PETUMT NO. ROAD PEJ AHT NO.
Date Applicant ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of TTi No — ��� ~U eASMerT racorm LNSTR NO. DATE '
Exemption, you should become subject to the Workers
LEGAL
Compensation provlslorts'of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.yyVENWxi
comply with such provisions or this permit shall be deemed
revoked. eLOoc TRACT STATE EN0X0AQiMENT
LICENSED CONTRACTORS DECLARATION VNI NO.of&Dd& PERAVT NO.
SM OF LOT NOW ON LOT
I heFeby affirm that l am licensed under provhldrn of Chapter USE OF
9 (commencing with Section 7000) of Division 3 of t� Busl- CHARM
nen and Professions Code, and my license Is In full force and
effect. CONTRACTOR
CHARGE FEE
License Number Llc.Clay ADDFJ56 FEE
PRO
ContractorCITY Date ILL.NO. DWIba NO. otrOUP AW
/ �'�'
`�'rvJ dam.
El am exempt under Sec. of the LA STATE LTC `/I ,Co. LASE NO. CUSS r
O
DESMW FEE
Plumbing Code and/or Sec. of the �' �oN� NAL C
HOUR 8. b P. Code for the following reason
�COtl4ECTNCi-TO DATE 111.4 VALIDATION
TTs
Par cot P At
PDRArr4nn
Date HOUSE ER OOPlICTM TO trr
gwr
Signature COfiii"T ADDm c*4A.L muG.OR Cn
OWNa-BUILDER DECLARATION vac TO HOUSE SEWERPIT Z
.1 hereby affirm that I am exempt from the Contueractor's LicerExTx MArNgr
Low for the following reason (Sectcn 7031.5, Bulanew and Pro. REP"01 u
10
fa �YETiw.HOua ACCT.�
sstons Code): •
❑ I,d owner of the property,or my employees with wages as
their sole compensation, will do the work and the structure 3307 27.50
Is not Intended or offered for sale (Section 7044, BuRiness
and Professions Code). OWNER'S Permit s 1 ITE }
❑ 1,as owner of tis*property,am exclusively contracting with AUTHORIZATION TOTAL FEE TUiL 27.50
licensed contractors to construct the project (Section 7044, 1 HAV! AT THZ DATE A CONTRACT MTfH THE HEREW MAM® CONTRACTOR TO
Business and Professions Code}. COMlCT TTf ASOVe DESMOM PQSTMO Dwe.LMo TO THE PLANK SEVAR GECK 27.50
CONSTRUCTION LENDING AGENCY t�,�y� rTyyTr
I hereby affirm that there Is a construction lending agency SIC�T®THIS Y OF 1$ �+ NE, t.{T ■w
for the performance of the work for which this permit is
Issued (Sec. 3097, Civ. C). ADORISS ...� 0004-0001 111 5/89Lenders Name
Lenders,Address 6471 1 AM11:41
I certffy that I have read this application and state that the
above Information is correct. t ogree to comply with all County
ordinances and State Ipws regulating Plumbing and-Sewers,
and hereby authorize representatives of this County to enter
upon the abov entioned property for Inspection purposes.
-a
Ig of Permittee Date fie QVfK!TOR DCP11-ANA704tY 4AHQU4d!