HomeMy Public PortalAbout5805 1/2 ENCINITA AVE_Sewer__ WORKERS' COMPENSATION DECLARATION �S
I hereby affirm that I hove a certificate of consent to self 20 D051 DPW 6189 U
Insure, or a ce lifitate of Workers' Compensation Insurance. or 76A642D
a ce.tin;d copy thereof (Sec 3800, Lab C.I APPLICATION FOR PERMIT
Poly No. Company
❑ Certlfied copy is hereby furnished. SEWER - SEWAGE DISPOSAL
❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Date Applicc mt FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDRESS Q ,T Fj C�i I STATION DEPTH
(This section need nal be completed if the work involved by the MANHOLE REVERENCE UPPER
ollars
permit is for one hundred d (5700)or less.) LOCALITYLOWER
NEAREST 1,� ' TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this GROSS ST. WcyKILjoc 4 VIL Y CURB PL ML TORI
permit is issued. I shall not employ any person In any monner LEGAL PC NO
BO as t0 become subject 10 the Workers Compensation Low; DESCRIPTION LOT.NO. CO IMP NO JOB NO
L/r/f//q BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
Dater ApT If. l -
ABSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
NOTICE TO APL CANT: If, after making this Ce ificc of MAP BOON PAGE PARCEL
Exemption, you should become subject to the Workers' NO.OF BLDGS.
Compensation provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT HWY OR ST WIDENING
comply with such provisions or this permit shall be deemed USE OF
revoked. BUILDINGS STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION i PERMIT NO
I hereby affirm shot I am licensed under provisions of Chapter OWNER
9 (commencing with Section 7000) of Division 3 of the Busi- MAIL
ADDRESS E�cl 'Gl CHARGES
ness and Professions Code, and my license is in full force and t �^�.E 1 _
effect. CITY 1/1`-50 i TEL N0. I. S 3 CONNECTION CHARGE FEE
License Number Lic.Class REIMBURSEMENT FEE
CONTRACTOR
Contractor DOIe DISTRICT NO G40UPMAP PROCESSED B�
ADDRESS B[ PG
❑ I am exempt under Sec. of theL.A. Co. O
CITY LEL NO.
PI umbi ng Code and/or Sec. ofthe STATE 0C. NNAI O
LICENSE NO CLASS DATE /j VAILIDA
B. 8 P. Code for the fallowing reason NO. DESCRIPTION OF WORK FEE /� 0
HOUSE SEWER CONNECTING TO RNAs F
Dote I PUBIC SEWER BY Q
SEPTIC TANK SEEPAGE PIT GR W
Signature PITS AND OR DPAINFIEUD W
g OWNERBUILDERDECLARATION HOUSE SEWER CONNECwG TO D z
PRIVATE 01SPOSAl SYSTEM
I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR
Low for the following reason (Secton 7031 5, Buisness and Pro- WORK TO HOUSE SEWER 10
fessions Code) OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.CESSPOOL.DRYWELL,MANHOLE
E:1 1,as owner of the property,or my employees with wages as ALTER,REPAIR OR ABANDON HOUSE ACCT.e
SEWER OR DISPOSAL SY57EM
their sole compensation, will do the work and the structure ;ju7 691 CIO
is not intended or offered for sale (Section 7044, Business
I/nd Professions Code). 1 !TEMEi
ACJ I. as owner of the property,am exclusively contracting with OWNER'S Permit c c-vt-E
licensed contractors to construct the project (Section 7044. $ 20 Y-'� TiITAL O LJ LJ
Business and Professions Code). AUTHORIZATION TOTAL FEE UlJ CHECK 59.011
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CIHIPA-TOR TO
I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING D'NEtING TO THE PUBIC SEWER
D CHANGE .l 13
for the performance of the work for which this permit Is ull\
issued (Sec. 3097, Civ, C.). SIGNED THIS DAY OF 19_
OWNER OR r,_U _r' •U 9 V
Lender's Name OWNERS AGENT CI(IO -0001 JI 1.
Lender's Address ADDRESS 3�7 - 1 AN10: tj
v.L Gl
I certify That I have read this application and store that the
above information is Correa. I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upon the above-men Yo ed grope ty for inspection purposes.
-a/ 3M IG
Signature of Permittee Dale �— SEE REVERSE FOR EXPLANATORY LANGUAGE