HomeMy Public PortalAbout5827 ENCINITA AVE_Sewer__ WORKERS`COMPENSATION DECLARATION -
I hereby affirm thot I have a certificate of consent to self 1 '
insure,ro:6 certificate of Workers'Compensation Insurance, or 70A64213
a certified copy thereof (Sec. 3800, Lab C.) 1R-OKXP DPw 91e8 APPLICATION
FOR P21�p(aIT
Policy No, Company 6"il(" ,ILL'` R - OCIG Pl 1511AL Y• `
❑ertified copy is hereby furnished. SEWER SEWAGE DISPOSAL
Certified copy 's filed with the county buil inspection COUNTY OF LOS ANGELES - BUILDING AND SAFETY
depo tm 1.
Date - pplicant ' —e'¢� FOR APPLICANT TO FILL IN CONNECTION DATA
CE TIFI ATE OF EXEMPTIO FROM WORKERS' BUILDING
ADDRESS J �27
iii7j° STATION Dearth
COMPENSATION INSURANCE
(This section need not be completed if the work involved by the - MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY (' T LOWER
I certifythat in the performance of the work for which this NEAREST TYPE OF CONNECTION M.L.LENTO FROM
p CROSS ST R 0. CURB P,L. M.L.TO P.L.
permit is issued, I shall not employ any person: in any m nner' _
so as to become object to the Workers' ompCO.IMP.NO.ensation ws. OWNER PC NO
G O!/�•'I ' LOB NO.
/' MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
Date T;/pplicant ADDRESS D YeD
NOTICE 70 A PLIC!{NT: If, ter makingthis Certificate Of .� AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.Np, DATE
CITY TEL.N0. i7
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith . DESCRIPTION LOT NO. HWY.OR ST.WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT S STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATIONNo.OF BUDGE, PERMIT NO.
I hereby affirm that I am licensed under provisions of Chapter
SIZE LOT Now ON LOT
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES
ness and Professions Code, and my license is in full force and d. � �.p��
effect. �J CONTRACTOR w'pZ25 l-(9lEsx i-VP7Y0/'lIl CONNECTION CHARGE FEE
License Number G L • c.Class ADDRESS 1 / / 62�320 r �'/C REIMBURSEMENT FEE
COnfiroCto e� 0 / p DISTRICT NO. GROUP MAP PROCESSEEDD BY
CITY y/ TEL NO. V 7�/ BN PG
❑ am exem t oder Sec. of the L.A.Co. SraiE uC. l/L-rty_/ r
p 1l O
p LICENSE NO. 3/ Z CLA55 � � D lJ O
Plumbing Code and/or Sec. of the NO. DES IPTION OF ORK FEE FINAL
HOUSE SEWER CONNECTING TO /'-]_ ?l DATE ', ,// VALIDATION LY
B. 8 P. Code for the following reason PUBLIC SEWER '/ l/ O
SEPTIC TANK,SEEPAGE PIT OR FINAL f'-'
Date PITS AND/OR DRAINFIELD BY U
HOUSE SEWER CONNECTING TO W
PRIVATE DISPOSAL SYSTEM
S'g t CONNECT ADDITIONAL BLDG.OR - (n
��p WORK TO HOUSE SEWER
OWF4t -BUIL E DECkkRA i0 \
OVERFLOW SEEPAGE Pli,DRAINFIELD —
I hereby affirm that I am exempt from the Contractors License EXTN.,CESSPOOL,DRYWELL,MANHOLE 1Q
Law for the following reason (Secton 7031.5, Buisness and Pro- '" ALTER,REPAIR OR ABANDON HOUSE -
fesslons Code): SEWER OR DISPOSAL SYSTEM ACCT�a
El 1,as owner of the property,or my employees with wages as
_their sole compensation, will do the work and the Structure 330-F 27.50
is not intended or offered for sale (Section 7044, Business+' .. 1
and Professions Code). OWNER'S Permit $ v ITEMS
-
❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION I TOTAL FEE 5 TOTAL 2-7 .511
licensed Contractors t0 construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO Gr1ECP '1'1.Cfl
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CHECK L2 5
CONSTRUCTION LENDING AGENCY - NAME—- •QQ
I hereby affirm that there is a construction lending agency SIGNEDTHIS DAY OF 19_ D _ x
for the performance of the work for which this permit is OWNEROR
AGENT
issued Sec. 3097,Civ. C.). �qy� { 1
( ADDRESS QOUIr QQQl 1213618
Lender's Name _
Lender's Address 7494 1 AM11:32
I Certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorize representatives pf this County to enter
upon the a ov ntioned pro y /inspection purposes./
—�gr ur err( a Date T SEE REVERSE FOR EXPLANATORY LANGUAGE