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HomeMy Public PortalAbout5225 FARAGO AVE_Sewer__ WORKERS" COMPENSATION DECLARATION �j I ')ere* affirm that I have a certificate of consent to self 76A DPW 8189 U Insure, or O certificate of Workers' Compensation Insurance, or A642D ICAe Pol crYlfNa t,py f ereof (Se Lab -�.L APPLP%T'®N FOR PERMIT ElCertified.- copy is hereby furnished. SEWER o SEWAGE DISPOSAL 0 Certified copy is filed with the coty ng I ection COUNTY OF LOS'ANGELES BUILDING AND SAFETY department Date / pplicant FOR APPLICANT TO FILL IN CONNECTION DATA/ CERTIFICATE OF EXEMPTION FROM ORKFRS' BUILDING STATION �� y-�� DEPTH (� COMPENSATION INSURANCE ADDRESS (This section need not be completed if the work involved by the LOCALITYs MANHOLE REFERENCE U permit is for one hundred dollars ($100)or less.) LOWER NEARESTTYPE 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 P c NO so as to become subject to the Workers' Compensation Laws. DESCRIPTION LOT NO. CO IMP NO JOB NO BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO Date Applicant ASSESSOR AFFIDAVIT I WAIVER EASEMENT RECORD INSTR NO DATE NOTICE TO APPLICANT: If, after making this Certificate of 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 v���-•-L�i' /"'/�'�� STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATIONPERMIT 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 ��^! - Hess and Professions Code, and m,/license CHARGES license is in full force and �J effect. // �7J CITY TEL.NO. ! �" CONNECTION CHARGE FEE License Number 4766 7 Lic.Class 67— ✓ld I ' � REIMBURSEMENT FEE �/ /� h CONTRACTOR COntraclOzI� Date �D/ /�� (T DISTRICT NO GROUP MAP PRO SSED BY ADDRESS `.-mss • BK PG El am exempt under Sec. of the L.A.Co. CITY �.cJ G r€L.NO.�7 /S-3 © P�: a Plumbing Code and/or Sec. of the STATE LIC. /� FINAL U LICENSE NO. CLASS L DATE (� 1` VALIDATION B. 8 P. Code for the following reason NO. DESCRIPTION OF o WORK FEE 1W GL 0 HOUSE SEWER CONNECTING TO FlNAL p_. Date PUBLIC SEWER BV U SEPTIC TANK SEEPAGE PIT OR Wd Signature PITS AND OR DRAINFIELD OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING TOPRIVATE DISPOSAL SYSTEM ® { a I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR •Jw9J7 .t� C�n '= Law for the following reason (Secton 7031.5, Buisness and Pro- WORK TO HOUSE SEWER feSsiOr1S Code OVERFLOW SEEPAGE PIT DRAINFIELD LL�� I EXTN.CESSPOOL DRYWELL.MANHOLE ER-COR ❑ I,as owner of theproperty, or m employees with wages as ALTER, REPAIR OR ABANDON HOUSE ;s.Zp #' f;, i their sole compensation, will do the work and the structure SEWER OR DISPOSAL SYSTEM 'Mi ':I amu° is not intended or offered for sale (Section 7044, Business 10 and Professions Code). A r. .y g ❑ 1,as owner of the property-am exclusively contracting with �••f�' 't °T licensed contractors to construct the project (Section 7044, OWNERS Permit $ Z '�) 3307 66°c- 07 Business and Professions Code). AUTHORIZATION TOTAL FEE CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO 'IITEMS' I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER ® �—c for the performance of the work for which this permit is TOTAL ^IT I _e ® 3 SIGNED THIS DAY OF 19_ issued (Sec. 3097, Civ. C.). V 6u OWNER OR �-'��"":Il Lender's Name OWNERS AGENT 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 CountyI_�i! t'j lo/- and %r 9 P Y c �o E� io 1 lI�E„•L! ordinances and State laws regulating Plumbing and Sewers, and hereby author'ze representatives of this County to enter ?i 4';L11_ upon the ov ione property for inspection purposes. !�0"A Si nature of ermittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE