HomeMy Public PortalAbout5801 ENCINITA AVE_Sewer__ WORKERS' COMPENSATION DECLARATION �i
200051 DPW 6819
I hereby affirm that I have o certificate of consent to self u
Insure, or a certificate of Workers' Compensation Insurance. or ompen76AET
a certified copy thereof (Sec. 3800. Lob C.) APPLICATION FOR PERMIT
Policy No, Company
❑ SEWER - SEWAGE DISPOSAL
Certified copy Is hereby furnished.
❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Date ' Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
' CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING — R�F� STATION DEPT«
COMPENSATION INSURANCE AODRE55 ////
(This section need not be completed if the work involved by the MANHOLE REFERENCE LOWER
permit is for one hundred dollars ($IDD)or less.) NEARESTLOCALITY / TYPE OF CONNECTION LENGTH FROM
LOWER
NEAREST
certify that in the performance of the work for which this GROSS ST. v - CURB WL ML TOOL
permit is issued, I shall not employ any person in any manner LEGAL
WC No
Bo as la become subject 10 the Workers' Compe ation Lows. DESCRIPTION LOT NO.
CO IMP NO TOB NO
/ BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
f / Date�LAppliconl� - ASSESSOR AFFIDAVIT WAIVER EASEMENT RECOPD INSTR NO DATE
VVV NOTICE TO APPLICANT: If, after making If Cer kale Of MAPBOOK I PAGE PARCEL i
Exemption, you should become subject to the Workers' No,OF BLDG$.
Compensotibn provisions of The Labor code, you must forthwith SIZE OF LOT NOW ON LOT HWY OP ST WIDENING
comply with such provisions or This permit shall be deemed 0SBUT OF
revoked. BUILDINGS •1 /� l STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATIONE k7T PERMn No
I hereby affirm that I am licensed under provisions of Chapter OWNER 11C (Y/ / e
9 (commencing with Section 7000) of Division 3 of the Bust- MAIL
ADDRESS ' 16 CHARGES
tress and Professions Code, and my,license is in full force and LTv
e}tech CITY 4ag TEL NO.
a v'S CONNECTION CHARGE TEE
License Number LIC Glass REIMBURSEMENT FEE
CONTRACTOR E
DISTRICT NOGROUP MAW PROCESSED BY
Contractor Date
ADDRESS r v!� 2 BK PG
❑ 1 am exempt under Sec. of the I.A.Co. / >
CITY TEL.NO. a
Plumbing Cade and/or Sec. of the STATE LIC, FINAL V
LICENSE NO. CLASS DATE V LID TION Z
B. 8 P. Code for the following reason NO. 1 DESCRIPTION OF WORK FEE p
HOUSE SEWER CONNECTING TO Q L FINAL F
Date I PUBLIC SEWER 43 J BY U
SEPTIC TANK SEEPAGE PN OR W
G.
Signature PITS AND OR GRAINFIELD
HOUSE SEWER CONNECTING 10 D Z
OWNER-BUILDER DECLARATION PRIVATE DISPOSAL SYSTEM
I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG 09
Law for The following reason (Season 703).51 Buisness and Pro- -WORK TO"ouPA SEWER f1
OVERFLOW SEEPAGE PIT.GRAINFIELD _
fCssiOnS Code): EaiN,CE55FOOL ORYWELL MANHOLE �{'{ 1
❑ a owner of the property, or my employees with wages as ALTER. REPAIR OR ABANDON HOUSE "'�'`"LCT.
SEWER OR DISPOSAL SYSTEM
their sole compensation, will do the work and the structure 13I37 s�4,1;14
s t intended or offered for sale (Section 7044, Business
OProfe
1 ITE
NS Code). rIS
I, as owner of the property, am exclusively contracting withOWNER'S Permit S Lp�j T!i TAL 69 - 00
licensed contractors to construct the project (Section 7044,
Business and Professions Code). AUTHORIZATION TOTAL FEE 0 CHECK 64,00
CONSTRUCTION LENDING AGENCY I "AVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR 70 E,
1 hereby affirm that there i5 a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWEP D (.HAN6E . ,UQ
for the performance of the work for which this permit Is
Issued (Sec. 3097, Civ. C.). SIGNED THIS_DAY OF ro_
OWNER OR oor,�,-ooui „ a/
Lender's Name OWNERS AGENT
JiV 1
Lender's Address ADDRESS
AN10:0 1
I certify that I have read this application and stole That the
above information is correcl. I agree to comply with all County '
ordinances and State lows regulating Plumbing and Sewers,
/ lb
nd herebyauthorize representatives of this County to enter
n the aove-menY ned prop try for inspealo Purposes.SignoTore of er tit D�� j SEE REVERSE FOR EXPLANATORY LANGUAGE