HomeMy Public PortalAbout5430 ENCINITA AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm -that I have o certificate of consent to self
insure,•or 6 certificate of Workers'Compensation Insurance, or 76Afi°21) - 2 �j'
a certified copy thereof (Sec. 3800, Lob C. 92-0002 DPW 6189 • p, PP C A TION ICOR PERMIT
PPIoli/K No. Company YU ,ILpI'lapir9 Ilrl 9tl9
xiJ (Certified copy is hereby furnished. SEvvEIM1�- SEWAGE DISPOSAL
(❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
departm m.
Date_h ���pplicant FOR APPLICANT TO FILL IN CONNECTION DATA
ERT ICA OF EXEMPTIO WORKERS' BUILDING �—
COMPENSATION INSURANCE ADDRESS Q yL �j/ri in T �)vt STATION DEPTH
(This section need not be completed if the work involved by the - - MANHaE REFERENCE UPPER
permit,is for one hundred dollars ($100)or less.) LOCALITY LOWER
NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. Y. CURB P.L. M.L-TOP.I.
permit is issued, I shall not employ any person in anyTmanner P.C.NO,
so as to become subject to the Workers'Compensation Law . OWNER � 0, 1 - CO.IMP.NO. JOB NO.
MDD " £j� TRUNK PERMIT NO, ROAD PERMIT NO.
Date � I pli<ont � ADDRESS V
Aff(DAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
NOTICE T A PLICA: If, after making this Certificate of CITY L 07—
Exemption, you should become subject to the Workers' LEGAL
Compensation plOvi510n5 Of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING
comply with such provisions or this permit shall be deemed i•
revoked. BLOCK TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO.of PERMIT No.
LOT
SIZE OF LOT NOW ON LOT CIO
I hereby affirm that I am licensed under provisions of Chapter WE of
9 (commencing with Section 7000) of Division 3 of the Busi-, - - BUILDINGS - CHARGES
ness and Professions Code, and my license is in full force and
effect. CONTRACTOR CONNECTION CHARGE FEE
License Number §ft/ 7! L'c.ClassADDRESS a REIMBURSEMENT FEE
COntracto e l DISTRICT NO. GROUP MAP PROCESSED BY
CITY TEL.NO. (O r C-L BK PG
STATE yy LIC. //�c J,C }
❑ am exempt under Sec. of the L.A.Co. ucENSE NO. 77 q2 aA55 l/O a
,NO. DESCRIPTION OF ORK RE O
Plumbing Code and/or Sec. of the \(
DATE \
' - HOUSE SEWER CONNECTING TO O DATE n 1; VALIDATION
PUBLIC SEWER �
J u
B. 8 P. Code for the following reason ti O
SEPTIC TANK,SEEPAGE PIT OR FINAL 0
PITS AND/OR DRAINFIELD
HOUSE SEW ER CONNECTING TO - BY W
PRIVATE D6POSAl SYSTEM
-' a
Signature— - CONNECT ADDITIONAL BLDG.OR (n
WORK TO HOUSE SEWER
OWNER-BUILDER DECLARATION - D Z
OVERFLOW SEEPAGE PIT,DRAWFI
I hereby affirm that I am exempt from the Contractor's License ExrNCESSPOOL.ssPooL.DRvwEMANHOLE _ , -
Low for the following reason (Sectors 7031.5, BUisneSs and Pro-, ALTER,REPAIR OR ABANDON HOUSE 'p .. ._.......
fessions Code): SEWER OR DISPOSAL SYSTEM' ACCT.a
❑ I,as owner of the property, or my employees with wages as - x107 27���1
their sale compensation, will do the work and the structure 'J _ _
is not intended or offered for sale (Section 7044, Business •• ` • - `1 ITEMS
and Professions Code). OWNERS Permit 8TV 0
❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE TOTAL. 27 .50
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO GLICCV CL1
Business and Professions Code). r CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER . CHECK 2L7VV
CONSTRUCTION LENDING AGENCY CHANGE .00
I hereby affirm that there is a construction lending agency SIGNED THIS 'DAY OF 19_ D _
for, the performance of the work for which this permit is OWNER OR - '
OWNERS AGENT LryC{L�E'L ryr}L} ter/ (}
issued (SEC. 3097, Civ. C.). ADDRESS 0000-0001 12 Irj/p9
Lenders Name
Lender's Address 7100 1 AM11:32
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 Plum pg and Sewers,
and hereby authorize represents of S County to enter
upon the above- Toned ert fo sped ion purpose]j
a ermitt _ Date Tr— SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa