HomeMy Public PortalAbout5803 ENCINITA AVE_Sewer__ WORKERS' COMPENSATION DECLARATION 1�
1 hereby affirm that I hove a certificate of consent to self 20 W51 DPW 6T69 u
insure, or a certificate of Workers' Compensation Insurance, or 76A642D
a certified copy thereof (Sec, 3800, Lob C.) APPLICATION FOR PERMIT '
'
Policy No. Compony
❑ Certified copy Is hereby furnished. SEWER - SEWAGE DISPOSAL
❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Dale Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING E STATION DEPTH
COMPENSATION INSURANCE ADDRESS A00 tA - UPPER
(This section need nor be completed If the work involved by the /� MANHOLE REFERENCE LOWER
Per's is for one hundred dollars (51170)or less.( Loc4uTr L�
FROM
I certifythat In the performance Of the work for which this NEAREST TYPE OF CONNECTION ON AT LEN
TO PL
P CROSS ST. Y CURB P I LE E 10 P l
/permit is Issued, I shall not employ any person in any manner LEGAL - P C NO
so as to become subject to the Workers Compensation Laws. DESCRIPTION LOT NO. CO IMP NO JOB NO
•C/// LY/ BLOCK TRACT TRUNK ffRMIT NO ROAD PERMIT NO
Dote—
Apel icant VES
ASSESSOR AFFIDAVIT WAVER EASEMENT RECORD IN5T4 NO DALE
NOTIC TO APPLICANT: If, afte m king this Ce t Icote of MAP eoorc PAGE PARCEL.
Exemption, you should become subject to the Workers' NO,OF BLOCS.
Compensation provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT
"WY 0451 WIDENING
comply with such provisions or this permit sholl be deemed USE OF
revoked. BUILDINGS STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION L. PERMIT NO
I hereby affirm that I am licensed under provisions of Chapter OWNER
9 (commencing with Section 7000( of Division 3 of the Busl- MAIL
nes, and Professions Code. and m-1 license is In full force and AGoRESs CHARGES
effect. CITU 't d TEL.NO. CONNECTION CHARGE FEE
License Number LiC.Class '♦ /� REIMBURSEMENT FEE
CONTRACTOR V�(„�f/�j
COn VOcIO!—Dole DISTRICT NO GROUP MAP PROCESSED BY
' ADDRESS R BK PG
❑ I am exempt under Sec. of the L.A.Co. �'O✓ �,� >_CITY TEL.NO. a'
Plumbing Code and/or Sec. of the STATE LIG FINAL U
LICENSE NO. CLASS DATE �J,�J VA IDA O
B. 8 P. Code for the following reason NO. DESCRIPTION OF WORK FEE Ir ` Q
HOUSE SEWER CONNECTING i0 2 3 2 FINAL F
Date PUBLIC SEWEP [,_. By C.1
SEPTIC TANK SEEPAGE PIT OR W
Signature PITS AND OR DRAINTIETD N
OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING TO Z
PPIVATE DISPOSAL SYSTEM
I hereby affirm that I am exempt from the Contractor s License CONNECT ADDIIIONAL BLDG OR
Law for the following reason (Secton 7031 5, Buisness and Pro- WORK TO HOUSE SEWER 1
fessions Code): OVERFLOW SEEPAGE PIT.DRAINQLD
EFIN,CESSFCOI.ORYwEEL.MANHOLE h
ALTER REPAIR O4 ABANDON HOUSE At't'T vT
❑ t,their
owner of the property,will
o employees with wages re SEWER OR DISPOSAL SYSTEM
their sole compensation,sleda, fer will do the work and the structure ,5307 a7.CIU
s n Inge nded or offered for sale (Section 7044, Business _
d Professions Code). 1 !TEM'
1, as owner of the property, am exclusively contracting withy
licensed contractors to construct the project (Section 7044, OWNER'S Permit $ ZS 0 TOTAL 69.- 00
Business and Professions Code). AUTHORIZATION I TOTAL FEE (gyp CHECK u%'.LII
CONSTRUCTION LENDING AGENCY I HAVE At THIS DATE A CONTRACT Will, THE HEREINNA MED CONTRACTOR IO
I hereby affirm that (here is o construction lending agency CONNECTHE ABOVE DESCRIBED ExISTING DWELLING To THE PUBLIC SEWER D lH1 NII �U�(
for the performance of the work for which this permit Is
issued (Sec 3097, Civ. C.). SIGNED THIS �_ DAY OF E'�"'Y �✓ 19 I-�
OWNFRO4 }_J�—JUOS Of' 3101
Lender's Nome OWNERS AGENT I I1)') I
Lender's Address AODRESs Jei
v ,g 1 ANIO:0?
I certify that I have read this application and state Thor The
above information is correct. I agree to comply with all County _
ordinances and Slate laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upon the above-me,,I a edproper y for inspection purposes.
Signature of Permittee Dale SEE REVERSE FOR EXPLANATORY LANGUAGE