HomeMy Public PortalAbout6324 ENCINITA AVE_Sewer__ WORKERS' COMPENSATION DECLARATION 1E0 0091 �i
I hereby affirm that I have o.,certificme of consent to self 76A642 DPW'B/R4 U
Insure, or a cerhficote.of Workers' Comp�ens tion n{urance, or 76A6420
a certified i� Se 3800, APPLICATION FOR PERMIT
Pdlcy N
❑ Certified copy is hereby furnished SEWER - SEWAGE DISPOSAL
[I Certified copy is filed wi41hcouny,b 'Idingms�pecf�n COUNTY OF LOS ANGELES BUILDING AND SAFETY
d � 1I �"'vDote ApplicanFORA PLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEM WORKERS' BwLDINc //7 /y'
COMPENSATION INSURANCE ADDREss �/ / stANDN DEPTH
(This section need not be completed If the work Involved by the LOCALITMANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) NEAREST LOWER
I certifyshot in the performance of the work for which this NEAREST TYPE OF CONNECTION N ML 1OTH FROM
p GROSS$T. V CURB P L M L 1OP l
permit is issued. I shall not employ any person In any manner LEGAL AC
NO
50 OS t0 bECOmC subject t0 the Workers' Compensation LAWS. DESCRIPTION LOT NO. CO IMP NO JOB NO
BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
Date Applicant
NOTICE TO APPLICANT: If, after makingthis Certificate of ASSESSOR AWIp.AvIT WAVER EASEMENT RECORD INSTR NO DATE
MAP BOON PAGE PARCEL
Exemption, you should become subject to the Workers' Na of aloes.
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 PERMIT NO
I hereby affirm that I am licensed under provisions of Chapter OWNER
9 (commencing with Section 7000) of Division 3 of the E i- MAIL
Ness
ADDRESS CHARGES
effe and Professions Code, and my license is in full force and
e4fEC1. CITY TEL NO. CONNECTION CHARGE EEE
License Num r(Y/ 99 LIC.CIOs$ `-'//// REIMBURSEMENT FEE
AV CONTRACTOR
Contractor v are /, DISTRICT NO GROUP MAP PROCESSED By
ADDRESS //,, VI Ba PG
El am exempt under Sec. Of the L.A.Co. CITY - 7� L No. — �'L J '� l_Nl Q
Pl u m bi ng Code and/or Sec. of the STATELIC
U . FINAL Y U
LICENSENO / CLASS DATE VA IDATI Z
B. 8 P. Code for the following reason NO. DESCRIPTION OF WORK FEE _ O
HOUSE$EWER CONNECTING t0 FINAL ♦-
Date I PUBLIC SEWER By V
W
SEPTIC TANK SEEPAGE PIT OR 11
Signature PITS AND OR DRAINERS Q)
OWNER-BUILDER DECLARATION OUSE SEWER CONNECTING To D Z
PRIVATE DISPOSAL SYSTEM
hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR
Law for the following reason (Secton 7031.5. Buisness and Pro- WORK TO ROUSE SEWER iQ
fe55iOn5 Code OVERFLOW SEEPAGE PIT DRAINNELD
I ExTN CESSPOOL ORYWELL.MANHOLE
❑ I, OS Owner of the property, Or my employees with Wages OS ALTER,REPAIR OR ABANDON HOUSE ACCT.r
their sole compensation, will do the work and the structure SEWER OR DISPOSAL SYSTEM 330; ' 73.50
is not intended or offered for sole (Section 7044. Business _
and Professions Code). 1 ITEMS
EMS
❑ I, CIS Owner Of the property, am exclusively contracting with OWNER'S Permit S TOTAL J e r
licensed contractors to Construct the project (Section 7044,
Business and Profession:Code). AUTHORIZATION I TOTAL FEE _ CHECK 73,50
CONSTRUCTION LENDING AGENCY I HAVE At CHIS DATE A CONTRACT wflH THE HEREIN NAMED CO rPACTOR t0
I hereby affirm that there is O construction lending agency CONNECT THE ABOV DES IBED EXISTING Dov G TO THE PUBLIC SEWER D CHANGE .00
for the performance of the work for which this permit is L//�j
issued (Sec. 3097, Civ. C.). SIGNED THIS LAY OF 194
OWNER OR 0000-0001 5/13/95
Lender's Name OWNERS A I
Lender's Address ADDRESSrlzz 6352 1 AM 8:0_t
I certify that I hove read this opplicotion and state that the
above information is correct. I agree to comply with all County
ordinance od State laws regulating Plumbing and Sewers,
and f by urhortze representatives of this County to enter
Up he abo e• entio ed property for I :RI purposes
,
7, l�
Signet re of Permittee Dote SEE REVERSE FOR EXPLANATORY LANGUAGE