HomeMy Public PortalAbout6018 ENCINITA AVE_Sewer__ WORKERS'COMPENSATION DECLARATION 76A642D APPLICATIONCE 808 (280) FOR PERMIT 1 hereby affirm that I have certificate of consent to self SEW ER-SEW GE DISPOSAL I
(
insure, or a certificate Workers'
rs'Compensation Insurance,or
a certified copy thereof(Sec. 3800.Lab. C.) COUNTY OF LOS ANGE -ES � � BUILDING AND SAFETY
Policy No. Company
❑ Certified Copy is hereby furnished. FOR APPLICANT TO FILL IN /CONNECTION DATA
BUILDING /O/6 /n. STATIONTI� DEPTH
XAr
❑ Certified Copy is filed with the county building inspection ADDRESS 0 �{/
department. LOC pL1TV MANHOLE REFERENCE uS3 LOWER
Dale Applicant NEARESTTYPE OF CONNECTION LENGTH FFOM
CERTIFICATE OF EXEMPTION FROM WORKERS' cRoss sr. O /4 Y.
Cuwe R.L. M.L. TO P.L. " Cz
I COMPENSATION INSURANCE �J //ff /) O P.C. NO.
OWNER [� / /[p CO. IMP. NO. / / 4 JOB NO. }
MAIL a
(This section need not be completed if the work involved ADDRESS �. TRUNK PERMIT NO. ROAD PERMIT N O
by the permit is for one hundred dollars (5100) or less.) PP,O.v, ,vE EMeNT R �OwO. .NSTR. .+ DATE U
C ITVNO.
I certify that in the performance of the work for which this L GAL 6� �.�p 0
permit is issued, I shall not employ any person in any manner DESCRIPTION OT NO. HWY. OR ST. w10ErvlN ` j O
so as to become subject to the Workers' Compensation Laws. U
BLOCK TRACT STATE ENCROACHMENT W
Date Applicant NO. OF BLDGS. PERMIT NO. d
SIZE OF LOT NOW ON LOT N
NOTICE TO APPLICANT: If, after making this Certificate Of Z
Exemption, you should become subject to the Workers' USE OF eHpwews
Compensation provisions of the Labor Code, you must forth-
BUILDINGS
with comply with suchpIOvisVIs10n5 O! Ihls permit shall bC CONTRACTOR CONNECTION CHARGE FEE
deemed revoked.
REIMBURSEMENT FEE
LICENSED CONTRACTORS DECLARATION ADDRESS _
I hereby affirm that I am licensed under provisions of Chapter DISTRICT No. GROUP .
NpP Pc EO E
CITY TEL. NO. I BE
9 (commencing with Section 7000) of Division 3 of the Busi- /tel 2
ness and Professions Code, and my license is in full force and LIC /3fJ ENSE NO. CLASS 1611f
effect. ... I DESCRIPTION OF WORK FEE
HOUSE sewER CONNECTING To FINAL r r A�. VALI ATION
License Number Lia Class SEWER DATE„ k:'
sA.P.BE P oR
on
Contractor Date PITS TAND/CR o FINAL '� !
HOUSE s O BY
❑ I am exempt from the licensing requirements as 1 am a PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL G TO
V
licensed architect or a registered professional engineer WORK TO HOUSE SEWER
acting in. my professional capacity (Section 7051, BusOVERFLOW SEEPAGE PIT, DRAINFIELD
-
iness and Professions Code). RATE.,
ALYSS. REPAIR OR ABANDON OUSE
SEWER OR DISPOSAL SYSTEM
Lic.or Reg.No. Date
HOME OWNER.BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's OWNER'S Permit f
License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE '>9 2 T A
nesx d Professions Code): I.HAVE AT THI re A CoAVCrDTHE N NAMED CON- e s e 0
CONNECTRACTOR TO THE BOE ESCRIe ELI_
I, as owner of the property, will do Hie work and the rHE PUBLIC se OR.
structure is not intended or offered for sale (Section SIGNED THIS DAY OF t9_
7044, Business and Professions Code).
' HERS•GEnT
CONSTRUCTION LENDING AGENCY 2 e • 1 8 0 0
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is o 0 0 Q 0 0 1
issued (Sec. 3097,Civ.C.). Q 2 0 2-81
Lender's Name
Lender's Address ,
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 of this County to enter ,
upon a above-mentioned p rpev for inspection purposes.
}' SEE REVERSE POR EXPLANATORY LANGUAGE
Signature of M'�ttee Date