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HomeMy Public PortalAbout5434 ENCINITA AVE_Sewer__ WORKERS'COMPENSATION DECLARATION I hereby affirm •thin I hove a certificate of consent to self _ a insure;cV b certificate of Workers'Compensation Insurance, or 78A602D ' a certified copy thereof(Sec. 3800, Lab C.) 92-0002 DPW siee p PPq ��a�p TO®pR ®� P�Rpp�� Policy No. Company /"a IL CA N AR . �rtified copy is hereby furnished. SEWER - SEWAGE DISPOSAL /LJ Certified copy is filed with the county building m ect. COUNTY OF LOS ANGELES BUILDING'AND SAFETY depart 1 Date gpplicont FOR APPLICANT TO FILL IN CONNECTION DATA ' C RTI KATE OF EXEMPTION FROM WORKERS' BUILDING COMPENSATION INSURANCE ADDRESS J a STATION DEPTH ft733 (This section need not be completed if the work involved by the MANHOLE REFERENCE ' UPPER permit is for one hundred dollars ($100)or less.) LOCALITY T LOWER NEAREST TYPE OF CONNECTION TFROM I certify that in the performance of the work for which this caoss ST. .Y. . CUWL. RB P.L. M.t.TOO P.L.. permit is issued, I shall not employ any person in any m ner so as to become•sub'ecl to the Workers'Com ensu`on ws. _ P.B NO. P OWNER 1 CO.IMP.NO. � l00 NO. J MAIL / �.O TRUNK PERMIT NO., ROAD PERMIT NO, Date L 13 Applicant ADDRESS _ l ' NOTICE TO APPLICANT: If, after makingt s Certificate Of _51", ` ARIDAVIi WAIVER EASEMENT RECORD.INSTR.NO. DATE 2227AL TEL,NO. Exemption, you should become subject Id the Workers' LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed & Q 'revoked. BLOCK TRACT 1p S STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION No.OF SLOGS. PERMIT NO. SIZE OF LOT NOW ON LOT I hereby affirm that I-am licensed under provisions of Chapter USE OF 9 (commencing with Section 7000) of Division 3 of the Busk BUILDINGS CHARGES nets and Professions Code, and my license is in full force and effect. �/ //��/- CONTRACTOR ` CONNECTION CHARGE FEE License Number' 7 '�.Class / • ADDRESS J 1 e REIMBURSEMENT FEE Contract Ste /FA-3/15-7— DISTRICT NO, GROUP MAP PROCESSED BY �/ TEL NO. /U 1yJT } STATE Slq_ CLASS �UV C 3 BK PG C a ❑ I am exem under$ec. of the L.A.Co. LICENSE NO. F` ,I{.. O Plumbing Code and/or Sec. of the NO. DEtCRIPTION Of WORK FEE . FINAL C) 'HOUSE SEWER CONNECTING TO /l DATE / VALIDATION B. 8 P. Code for the following reason PUBLIC SEWER 0 ,i 0 SEPTIC TANK,SEEPAGE PIT OR FINAL f- Date PITS AND/OR DRAINFIELD BY U HOUSE SEWER CONNECTING TO Lll PRIVATE DISPOSAL SYSTEM Ld Signature CONNECT ADDITIONAL.BLDG.OR WORK TO HOUSE SEWER OWNER-BUILDER DECLARATION ' © Z OVERFLOW SEEPAGE PIT,DRAINFIELD hereby affirm that am exempt from the Contractor's License EXTN.,CESSPOOL,DRVWfII,MANHOLE A . . Law for the following reason (Secton 7031.5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM 8 ,. ACCT.. ❑ I, as owner of the property,or my.employees with wages as - L their sole compensation, Will do the work and the structure . _ - .3307 - -27.51( is not intended or offered for sale (Section 7044, Business permit $ O 1 ITEMS and Professions Code). OWNER'S ❑ 1, os 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 `L,L�//++I/ �'} Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. ' - ' CHECK 27.50 CONSTRUCTION LENDING AGENCY D CHANGE .00 I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_ for the performance of the work for which this permit is OWNER OR iSSUEd (SEC. 3097, Civ. C. OWNERS AGENT J. ADDRESS 0000—OMI 12/13/89 Lender's Name - Lender's Address 7502 1 AM11:37 I certify that I have read this application and state that the ' above information is correct. I agree to comply with all County .. r ordinances and State lows regulating Plumbing and Sewers, and hereby a ;horize representatives f this County to enter 'upon the a Toned pr ert r Inspection purset. . P� Si tu�er� Date f SEE REVERSE FOR EXPLANATORY LANGUAGE