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Home My Public Portal About5957 ENCINITA AVE_Sewer__ WORKERS' COMPENSATION DECLARATION hereby affirm that have a certificate of consent nc self 200051 DPW 6189 LJ Insure, ora<ernficole of Workers' Compensation Don Insurance. or 76A6420 a certified copy thereof (Sec. 3800, Lab C) APPLICATION FOR PERMIT Policy No. Company ElCertifiedcopy is hereby furnished. SEWER SEWAGE DISPOSAL COUNTY OF LOS ANGELES BUILDING AND SAFETY ElCertified copy is filed with the county building inspection department. t Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA V CERTIFICATE OF EXEMPTION FROM WORKERS" BUILDwG C — • STATION DEPT- COMr-IPENSATION INSURANCE ADDRESS (This section need not be completed If The work involved by the LOCALITY \�, MANHOLE REFERENCE DWER ( ) ) NEAREST permit is for one hundred dollars $100 or less. T 1Y°E OF CONNECTION FROM I certify that in the performance o4 the work for which this CROSSST. L_vt� M L TO r tufa PL ML TOPL permit is issued, I shall not employ any person in any manner LEGAL Pc NO So a5 tobecomesubject to the Workers' T nsaTon Laws. DESCRIPTION LOT NO. CO IMP NO JOB NO �� BLOCK TRACT tRUNK PERMIT NO ROAD PERMIT NO Dale C�1 Applicant NOTICE TO APPLICANT: If, after making This Certificate of MAPBOOq AFFIDAVIT OK EASEMENT RECORD INSTR NO OPIE MAP BOOK PAGE PARCEL Exemption, you should become subject To the Workers' No.of efocs. 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 sholl be deemed USE OF revoked. BUILDINGS STATE ENCROACHMENT PERMIT No LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter OWNER pv�[ 9 (commencing with Section 7000) of Division 3 of the Busi- ADDRESS 1✓ 1 F'nlu�� CHARGES ness and Professions Code, and my license is in full force and •�(� Q 1 effect. /� CITY \ TEL.NO.$1j — t 2 "ETHECIION CHARGE FEE LICEnSC NUmbEr ' LIC.Ca S$ l —�� ! \ REIMBURSEMf NT FEE --x' CONTRACTOR Contractor Date �+' �-L11 ` p DISTRICT NO GROUP u.A° _PROCESSED By 4 ADDRESS 1 -V p BK °G ❑ I am exempt under Sec. of the L.A.Co. CITY � TEL.NOR� �o �� p Z 5" Plumbing Code and/or Sec, of the STATE Ls�� LIG FINAL U LICENSE NO. qA, `�� CLASS DAZE ' A( VALIDATION Z B. 8 P. Code for the following reason NO. 1 DESCRIPTION OF WORK FEE •IP O HOUSE SEWER CONNECTING TO nNAT F Date Z'ZINE, PUBLIC SEWER BY W SEPTC TANK SEEPAGE PIT OR d Signature ./ IIS AND OR GRAINFIELD (A OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING TO DZ RIVAff PDISPOSAL SYSTEM 10 I hereby offirm Ihot I Om exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR Law for the following reason (Secton 7031.5, Buisness and Pro- WO.,TO HOUSE SEWER ACCT.i y fessions Code); OVERFLOW SEEPAGE PIT,DRAINF ELD ACCT. ExtN-CESSPOOL D4YWRIL MANHOLE ❑ I,as owner of the property, or my employees with wages as AtWER RE DISPOSAL ORALBANDON HOUSE 3303 73.50 their sole compensation, will do the work and the structure 1 ITEMS is not intended or offered for sole (Section 7044. Business and Professions Code). TOTAL 73 - 50 ❑ I, as owner of The property, am exclusively contracting with licensed contractors 10 construct the project (Section 7044, OWNER'S Permit $ Q CHECK 73.50 Business and Professions Code). AUTHORIZATION TOTAL FEE O CHANGE i00 CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONIRACT WITH THE HEREIN NA .ONI4AUOR To D I hereby offirm that there is a construction lending agency CONNECI tHF ABOVE DESCRIBED EXISTING DWELLING tO THE PUB IC SEw[R for the performance of the work for which This permit Is issued (Sec 3097, Civ. C.1, SIGNED THIS DAV OF 19_ M-0001 2!21/96 •�/,�\ OWNER o4 Lender's Name �J'�C__ OWNEERS AGENT 4945 1 AM .9:59 SS Lender's Address ADDR I certify that I have read this application and stale 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 Of this County To enter upon the abov Zone property for inspection purposes. A� e 2-u-�1I ^v' Signature of Permittee Date ` � SEE REVERSE FOR EXPLANATORY LANGUAGE