HomeMy Public PortalAbout5805 ENCINITA AVE_Sewer__ WORKERS' COMPENSATION DECLARATION I
7
I hereby of(irm that 1 have a'certificale of consent to self 6A642D
DPW 6189 u
rroure. or d certificate of Workers' Compensation Insurance. or 6A642
a cenified'copy thereof (Sec. 3800, Lob C.) APPLICATION FOR PERM17
Policy No. Company
❑ Certified copy Is hereby furnished. SEWER - SEWAGE DISPOSAL
❑ Cerlified copy Is filed in 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' BUILDINGL STATION DEPTH
COMPENSATION INSURANCE ADDRESS -O'A'
(This section need nor be completed if the work involved by the LOOAUTY -yyy., I �. MANHOLE REFERENCE UPPER
permit is for one hundred dollars (8100)or less.) LOWER
I certifyperformance Of the work for which this NEAREST TYPE OF CONNECTION LENGTH POM
Thal in the p CROSS ST. (N Y CURB P L M L i0 P l
permit is issued. I shall not employ any person in any manner LEGAL
AC No
so as t0 become subject 10 the_W rs Compensation Laws. DESCRIPTION LOT NO. co IMP NO lOB NO
BLOCK TRACT TRUN[PERMIT NO ROAD PERMIT NO
Dote AppI lconl
NOTICE TO AP UC To
f, after makingthis Cerr [Ole of MAPBOOK AFFIDAVIT WAVER EASEMENT RECORD INSTR NO DATE
MAP BOOK PgGE PARCEL
Exemption, you should become subject to the Workers' NO OF SLOGS.
Compensation provisions of The Labor code, you must forthwith SIZE OF LOT NOW ON LOT Hwv QRST WINNING
comply with such provisions or this permit shall be deemed ISE OF I '
revoked. BUILOw, STATE ENCROACHMENT
PERMIT NO
LICENSED CONTRACTORS DECLARATION h� D
I hereby affirm that I am licensed under provisions of Chapter pe
OWNER
9 (commencing with Section 7000) of Division 3 of the Busi- MAIL 2 G 1
ADDRESS l 42 CHARGES
Hess and Professions Code, and III license is In full force and �/
effect. CRY [{ TEL.NO. IVU CONNECTION CHARGE FEE
License Number Lic.Class REIMBURSEMENT FEE
CONTRACTOR
COnIrOCIOr Dote DISTRICT NO GROUP MAR PROCESSED BY
ADDRESS �zB+ PG
❑ I am exempt under Sec. of the L.A.Co. 5.05 �•3 Y
CITY TEL NO. BE.
O
Plumbing Code and/or Sec. of the STATE uc. PENAL U
LICENSE NO, CLASS DATE VALIDATION
Z
B. & P. Code for the following reason NO. DESCRIPTION OF WORK FEE
0
FU
I CONNECTING TO /1 .y AL
Dole EL C SEWER BY h
F J U
BILL
RTIC TD SEEPAGE PR OR d
Signature ITS AND OR
OR DRAIrvRF30
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 BUID OR
Low for the following reason (Section 7031.5. BVrSness and Pro- WOR[ 'O HOUSE SEWER jll
fessions Code): OVERFLOW SEEPAGE PIT. DRAINFIfLD
ExTN-CESSPOOL DRYWELL MANHOLE
At i
PG .T
❑ I, as owner of the property, or my employees with wages as s TER RE AIR OR ABANDON SYS . HOUSE
their sole compensation, will do he work and the structure 3207 69.10
is nor intended or offered for sale (Section 7044, Business
and Professions Code). f,1 ITEMS
69 - 00
las owner of he properly, am exclusively contracting with OWNER'S Permit S 2 TOTAL
licensed contractors to construct the project (Section 7044, - F
Business and Professions Code). AUTHORIZATION TOTAL FEE CHECK 69.11 i
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH IME HEREIN NAMED CONTRACTOR 10 Ch�ANf-E
I hereby affirm that 'here is o construction lending agency CONNECT THE ABOVE DESCRIBED ExISTING DIETING TD THE PUBLIC SEWER J .tiff
for the performance of the work for which This permit Is
issued (Sec. 3097, Civ. C.). SIGNED IHR DAY OF 19_ J
OWNER OR (II(EII1
Lender's Name OWNERS AGENT
ADDRESS h1n 1 A1niLl.�11
Lender's Address •�"`-
I certify that I have read This application and stole that the
above informalion is correct. I agree to comply with all County '
ordinances and Store lows regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
Upon the above-menllonedl`'p��1y'///'�/�/�/rooppeee rrrtttyy{y for inspeection purposes.
ignoture of Perm t Dole SEE REVERSE FOR EXPLANATORY LANGUAGE