HomeMy Public PortalAbout5113 FARAGO AVE_Sewer__ WORKERS' COMPENSATION DECLARATION 20-0051 DPW 6189
I here* affirm that I have a certificate of consent to self
insure, or a certificote of Workers' Compensation Insurance, or 76A642D
a certified c c 3800, •9 ) /^ APPLICATION F PERMIT
Policy No.��ishereby
pany `�(/ !
❑ Certified cfurnished. 61
�J SEWER - SEWAGE DISPOSAL
Certified copy is filed with the county buil g ec n COUNTY OF LOS ANGELES BUILDING AND SAFETY
de r mens. .—
Date �ApIicont FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFI ATF EXE ON FROM WORKER BUILDING 11
COMPENSATION INSURANCE ADDRESS STATION DEPTH
(This section need not be completed if the work involved by theMANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY
41" LOWER
I certify that in the NEAREST TYPE OF CONNECTION LENGTH FROM
y performance of the w or which this CROSS ST. Y CURB P L M L TO P L
permit is issued, 1 shall not employ a erson in any manner LEGAL PC NO
so as to become subject to the ers' Compensation Laws. DESCRIPTION LOT NO. CO IMP NO JOB NO
Date pliCont BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
NOTICE TO LIC
If, after making this Certificate icote Of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
g MAP BOOK PAGE PARCEL
Exemptio 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 force and ADDRES _ CHARGES
effect. — CITY C TE O. �� CONNECTION CHARGE FEE
License Number iC.Class v `/ yREIMBURSEMENT FEE CONTRACTOR l N ��/ G`�
Contractor DISTRICT NO �O3UP MAP PROCESSED 8Y
ADDRES J�Jd� BK PG
Elc1TvI am exempt under Sec. of the L.A.Co. O �py _Oa-
O
Plumbing Code and/or Sec. of rhe STATELIC. FINAL V
LICENSE NO. l CLASS DATE VALIDATION
B. 8 P. Code for the following reason NO. DESCRIPTION OF WORK FEE Z
O
HOUSE SEWER CONNECTING TO FINAL f-
Date PUBLIC SEWER BY V
SEPTIC TANK SEEPAGE PIT OR LU
Signature PITS AND OR DRAINFIELD a
OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING TOPRIVATE DISPOSAL SYSTEM ® Z
I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR
Law for the followingSecton 7031.5, Buisness and Pro- WORK TO HOUSE SEWER
fessions Code): reason ( OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.CESSPOOL DRYWELL MANHOLE
�-..
❑ I, as owner of the property, or my employees with wages as ALTER,REPAIR OR ABANDON HOUSESEWER OR DISPOSAL SYSTEM .. _
their sole compensation, will do the work and the structure
is not intended or offered for sole (Section 7044, Business
and Professions Code).
❑ I, as owner of the property, am exclusively contracting with OWNERS Permit $
licensed contractors to construct the project (Section 7044, -- -- ---
Business and Professions Code). AUTHORIZATION TOTAL FEE =:1f .j:;:r "i
CONSTRUCTION LENDING AGENCY i HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACT R 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 t?r'y�tr;_r;;,::; y
issued (Sec. 3097, Civ. C.). SIGNED THIS DAY OF 19_ - -- --A•
OWNER OR '•vt•+,r .r,�. _
Lender's Name OWNERS AGENT
Lender's Address ADDRESS
I certify that I hove 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 tatives of this County to enter
upon the above- on d erty for inspection/ppu`rposes.
CY
g ature of Permitte D to SEE REVERSE FOR EXPLANATORY LANGUAGE