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HomeMy Public PortalAbout5233 FARAGO AVE_Sewer__ WORKERS' COMPENSATION DECLARATION 20-0051 DPW 6/89 1 hereby affirm that I have a certificate of consent to self 76A6a2D ins6re, or o certificate of Workers' Compensation Insurance, or Poler�ifneod cgpt ere f S c. '88 , Lgb-E� a,14-- APPLICATION FOR PERMIT ❑ Certified copy is hereby furnished. --� SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the county buil g;ins ecti COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Date pplicont dor FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTI FROM WORKERS' BUILDING COMPENSATION INSURANCE ADDRESS STATION DEPTH This section need not be completed if the work involved b the UPPER ( P Y /"�� MANHOLE REFERENCE LOWER LOCALITY a� permit is for one hundred dollars ($100)or less.) NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST. Y CURB PL MIL TOPIL 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 JOB NO Date Applicant BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO NOTICE TO APPLICANT: If, after makingthis Certificate Of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE MAP BOOK PAGE PARCEL Exemption, you should become subject to the WorkersNO.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 NOowNE I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Busi- MAIL �js CHARGES ness and Professions Code, and my license is in full force and ADDRESS ac y effect. CITY / ♦ TEL.NO. / (� CONNECTION CHARGE FEE License Numbe / Lic.Class �+ ��G �j �/ REIMBURSEMENT FEE C/!/�'7.. "I z/ —/ CONTRACTOR Contractor Date _ DISTRICT NO GROUP MAP PRO SED By ' EIADDRES BK PG©� !�I am exempt under Sec. of the L.A.Co. CITY — .NO. d Plumbing Code and/or Sec. of the STATE LIC FINAL O LICENSE N CLASS DATE _ `/f VALIDATION O B. 8 P. Code for the followingreason NO. DESCRIPTION OF ORK FEE �!/ Z HOUSE SEWER CONNECTING TO FINAL Date PUBLIC SEWER BY V SEPTIC TANK SEEPAGE PIT OR W Signature PITS AND OR DRAINFIELD _ EL OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING TOPRIVATE DISPOSAL SYSTEM I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR �^' Low for the following reason (Secton 7031.5, Buisness and Pro- WORK TO HOUSE SEWER 1V fesslons Code): OVERFLOW SEEPAGE PIT,DRAINFIELD V EXTN,CESSPOOL DRYWELL, MANHOLE ❑ I, as owner of the property, or my employees with wages as STER, REPAIR ABANDON HOUSE SE A�CT.®r their sole compensation, will do the work and the structure EWER OR DISPOO SAL SYSTEM 7- _; is not intended or offered for sale (Section 7044, Business o 34 07 .s: and Professions Code). 1 ITE�a ❑ 1, as owner of the property, am exclusively contracting with OWNERS licensed contractors to construct the project (Section 7044, E'FRTit $ 24 17 C TOTAL 66 - 53 Business and Professions Code), AUTHORIZATION TOTAL FEE { c-.1 CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO CHECK 6-b.-j6 I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER001 CHANGE for the performance of the work for which this permit Is C issued (Sec. 3097, Civ. C.). SIGNED THIS DAY OF 19_ OWNER OR Lender's Name OWNERS AGENT0000-000 1 10/3111! 5.."`• Lender's Address ADDRESS 6i73; { AM 9a11« 1 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 la regulating Plumbing and Sewers, and hereby outhori -r ese ves of this County to enter upon the ov enW6n d r erty for inspection purposes. Si nature otcKrmittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS' COMPENSATION DECLARATION 1 hereby affirm that I have a certificate of consent to self 6A641 DPW 6189 7 insure, or a certificate of Workers'Compensation insurance, or 6A6a2D a.certified'copy thereof (Sec.-1800, Lab C. APPLICATION FOR PERMIT Policy No. Company ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDINGSTATION DEPTH COMPENSATION INSURANCE ADDRESS (This section need not be completed if the work involved by the LOCALITYMANHOLE REFERENCE UPPER LOWER permit is for one hundred dollars ($100)or less.) TYPE OF CONNECTION NEAREST 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 anyma er LEGAL PC NO so as to become subject to the W ers' Compensation Lo s. DESCRIPTION LOT NO. CO IMP No JOB NO BLOCK TRACT TRUNK PERMIT NO -ROAD PERMIT NO Date/` Applicant NOTICE TO APPLICANT: If, after makin this Certificate Of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE g MAP BOOK 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 PERMIT NO LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter OWNER �f J 9 (commencing with Section 7000) of Division 3 of the Busi- MAIL CHARGES ness and Professions Code, and m,/license is in full force and ADDRESS effect. CITY TEL.NO. CONNECTION CHARGE FEE License Num L4, DL ic. Class REIMBURSEMENT FEE CONTRACTOR COntractOrate / (!/I•—J�1 J� ��JJ DISTRICT NO GROUP MAP PROCESSED By ADDRESS �(//n�/ BK PG ❑ I am exempt under Sec. of the L.A. Co. Plumbing Code nd/or Sec. of the STA uc. FINAL LICENSE NO. CLASS DATE VALIDATION B. & P. Co fo the following reason NO. 1 DESCRIPTION OF WO K FEE S O HOUSE SEWER CONNECTING TO FINAL III— at PUBLIC SEWER BY V SEPTIC TANK SEEPAGE PIT OR LU a Signatur PITS AND OR DRAINFIEID 03 OWNER- UIL DITRIIDTECLARATION HOUSE SEWER CONNECTING TO , Z PRIVATE DISPOSAL SYSTEM I 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 HOUSE SEWER ,,.3;01 1514.00 fes5iOn5 Code OVERFLOW SEEPAGE PIT.DRAINFIELD EXTN,CESSPOOL DRYWELL.MANHOLE j ITEMS ❑ 1, as owner of the property, or my employees with wages as ALTER.REPAIR OR ABANDON HOUSE i ITEMS F SEWER OR DISPOS L SYSTEM TOTAL :154 5�r m 00 their sole compensation, will do the work and the structure I�i L .d. ���' 4_P is not intended or offered for sole (Section 7044, Business E .5 c and Professions Code). CHECK 4.00 ❑ 1, as Owner of the property, am exclusively contracting with OWNERS Permit $ f HA •I-ll� licensed contractors to construct the project (Section 7044, Business and Professions Code). AUTHORIZATION I TOTAL FEE CONSTRUCTION LENDING AGENCY I HAVE AT THIS IDA TE CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO 1 hereby affirm that there is o Construction lending agency CONNECT THE ABOVE CRIB D EXISTING D' TO THE PUBLIC SEWER , 01000,—U Is I� 1 7 {rLj. for the performance of the work for which this permit Is ' :y i (y /°• issued (Sec. 3097, Civ. C.). SIGNED THIS OF 19 229 ONER OR Lender's Name OWNERS ADEN Lende S Address ADDRESS ce ify that I have read this application and state that the ab ve i pformation is correct. I agree to comply with all County or Ina es andlaws regulating Plumbing and Sewers, a d reby out rite eprese olives of this County to enter o h�eo ro -mens' d pr perty for inspection purposes. Sign to of Itiee Dae SEE REVERSE FOR EXPLANATORY LANGUAGE