HomeMy Public PortalAbout5107 FARAGO AVE_Sewer__ WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to se'If 20-0051 DPW 618976A6a2D
Insure„ oro certlfi ate of Workers' Com ensation Insurance, or
a'certifiedFJ� pa318 l It APPLICATION FOR PERMIT
Policy N / `l9
❑ Certified copy is he furnished. ell SEWER - SEWAGE DISPOSAL
�Certified copy is filed with the county bu�ldi ion COUNTY OF LOS ANGELES BUILDING AND SAFETY
d p trtlen �'
Da pplicant _ FOR APPLICANT TO FILL IN CONNECTION DATA
f f�
CERTIFICATE OF EXEMPTION FROM WOBUILDING
COMPENSATION INSURANCE ADDRESS STATION DEPTH
(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 LOWER
NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. Y CURB P L M L TO P L
permit is issued, I shall not employ any person in any manner LEGAL PC NO
so as to become subject to the Workers' Compensation Laws. DESCRIPTION LOT NO. CO IMP NO LOB NO
Date Applicant BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
NOTICE TO APPLICANT: If, after mpkin this Certificate Of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
g MAPBOOK 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 PERMIT NO
I hereby affirm that I am licensed under provisions of Chapter OWNER
9 (commencing with Section 7000) of Division 3 of the Busi- MAIL
ness and Professions Code, and my license is in full for a d ADDRESS �(/ �-- CHARGES
effect. �( �C?�/ CITY e
TEL. / CONNECTION CHARGE FEE
License Number Lic.Class J1� '/l.J CONTRACTOR iY V J REIMBURSEMENT FEE
COntroctor ate 7 .-i% DISTRICT NO GROUP MAP PROCESSED BY
��' sT ADDRES BK PG
}
❑ 1 am exempt under Sec. of the L.A.Co. CITY TEL.No. �2o�' ! � 0
Plumbing Code and/or Sec. of the STATE LIC. y FINAL0LICENSE NO. CLASS DATE / VALIDATION
B. & P. Code for the following reason NO. DESCRIPTION OF WORK FEE �/ 7 Z
O
HOUSE SEWER CONNECTING TO FINAL (-..
PUBLIC SEWER BY U
SEPTIC TANK SEEPAGE PIT OR LU
PITS AND OR DRAINFIELD a
Signature C0
HOUSE SEWER CONNECTING TO
OWNER-BUILD RATION PRIVATE DISPOSAL SYSTEM
I hereby affirmZ
that I am exe pt from the Contractor's License CONNECT ADDITIONAL BLDG OR }j
Law for the following reason (Secton 7031.5, Buisness and Pro- I WORK TO HOUSE SEWER
fessiOns Code): -
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN CESSPOOL DRYWELL.MANHOLE .....
El 1, as owner of theALTER REPAIR OR ABANDON HOUSE,property, or my employees with wages as SEWER OR DISPOSAL SYSTEM
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business
and Professions Code).
❑ I, as owner of the property, am exclusively contracting with . .Hi—
licensed
_
licensed contractors to construct the project (Section 7044, OWNER'S Permit $ -. _
Business and Professions Code). AUTHORIZATION TOTAL FEE
CONSTRUCTION LENDING AGENCY i HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED C NTRACTOR TO
I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER
for the performance of the work for which this permit is
issued (Sec. 3097, Civ. C.). SIGNED THIS DAY OF 19_ _
OWNER O
Lender's Name OWNERSAGENT _ •t'. " �~`/?"
Lender's Address 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 herebyauthorize sentatives of this County to enter
upon the above�ne o roperty for inspection purposes.
i
gnature o�ermiN Date SEE REVERSE FOR EXPLANATORY LANGUAGE