HomeMy Public PortalAbout5803 1/2 ENCINITA AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
herpby affirm that I have a certificate of consent ra self 20-DOST DPW 6189 u
asbre, or a certificate of Workers'Compensation Insurance. or 76A642D
o certified copy thereof (SAc. 3800, tob C.) APPLICATION FOR PERMIT
Policy No. Company ,EL, p p
❑ Certified copy Is hereby furnished- SEWER - SEWAGE DISPOSAL
❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
deportment.
Dote Applicant - FORAPPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS" BU'L 'S I STATION ocvTa
COMPENSATION INSURANCE ADDREGS �`
UPPER
(This section need not be completed If the work involved by the LOCAL - r' f Av"' E REFETt[NCE LOWER
permit is for one hundred dollars ($100) or less.) NEAREST
HFROM
I certifythat in the performance of the work for which this NEAREST TYPE CONNECTION .1, TORL
p CROSS ST. � Y CURB Pl Ml iOPI
permit is issued, I shall not employ any person In any manner LEGAL
9C NO
so az to became subject to the Workers' Compensation Laws. DESCRIPTION Lor No. co IMP No 10B NO
BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
Date Appbcan(
NOTICE TO PPLICANT: f, after making this' rt if ifate Of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSi4 NO DATE
MAP BOOK PAGE PARCEL
Exemption, you should become subject to the Workers' NO.OF BLDG$.
Compensation provisions of the Lobo,code. you most forthwith SIZE OF LOT NOW ON LOT wWY OR St WIDENING
comply with such provisions or this permit shall be deemed USE OF
revoked. BUILDINGS STATE ENCROACHMENT
PERMIT No
LICENSED CONTRACTORS DECLARATION h f
I hereby affirm that I am licensed under provisions of Chapter OWNER (� ,_,F
9 (commencing with Section 7000) of Division 3 of the Busi- aooRESs 2.r/ (,av
CHARGES
Hess and Professions Code. and my license is in full force and _
effect. CITY TEL NO, Q Q CONNECTION CHARGE TEL
License Number Lic.Class - REIMBURSEMENT FEE
CONTRACTOR
D151R1[i NO GROUP MGP PROCESSED BY
Contractor Dote /�(�.�
ADDRESS 5V V 3 BK PG
L1om exempt under Sec. Of the L.A.Co. u }
CITY TEL.NO, 0
O
Plumbing Code and/or Sec. of the STATELIG DATE
LICENSE
U
LICENSE NO. CLASS DATE _ VALIDATO Z
B. 8 P. Code for the following reason NO. DESCRIPTION OF WORK FEE O
MOUSE SEWER CONNECTING TO FINAL
Data PUBLIC SEWER BY 0
SEPTIC TANK, SEEPAGE PIT OR w
Signature PITSAND OR DRAINRELD y
OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING TO D Z
PRIVATE DISPOSAL SYSTEM
hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR
Law for the following reason (Secton 7031.5, Buisness and Pro- WORK TO MOUSE SEWER
OVERFLOW SEEPAGE PIT DRAINFIELD 1.I
fessions Code)' EATN.CESSPOOL DRYWELL MANHOLE
❑ I, as owner of the property, or my employees with wages as ALTER REPAIR OR ABANDON HOUSEa
SEWER OR DIS'OSAL SYSTEM �`T �
their sole compensation, will do the work and the structure
.,307 69.0[1Is n mended or offered for sale (Section 7044, Business
d Professions Code).
1 !TENS:
1,as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Section 7044, OWNER'S Permit $ 25(05 TOTAL 69 . 00
Business and Professions Code). AUTHORIZATION TOTAL FEE co '/ aii
CONSTRUCTION LENDING AGENCY i HAVE AT THIS DATE A CONTRACT W-nH THE HEREIN NAMED CONTRACTOR TO CHECK 02.01
I hereby affirm that there is a construction lending agency CONNECT THE ABOVE Of SCRIBED EKISTWG D'MUING TO THE PUBLIC SEWER D lltq`ILC
for The performance of the work for which this permit is - CHANGE V
Issued (Sec. 3097, Civ. C.). SIGNED THIS DAV OF 19_
C WNER OR t�
Lender's Name OWNERS AGENT
Lender's Address ADDRESS
I certify that I have read this application and state that the 1 QM 1fIC(J_
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
u on bove-mentioned property for inspection purposes. -
JA 3
Signa Nre f Pera SEE REVERSE FOR EXPLANATORY LANGUAGE