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Home My Public Portal About5237 FARAGO AVE_Sewer__ WORKERS' COMPENSATION DECLARATION I he20-0051 DPW 6189reby affirm that I hove o certificate of consent to self 76A642D insure, or',a certificate of Workers' Compensation'Insurance, or cf Policy No,. copy th/�i%% 38 G, La ) �� APPLICATION FOR PERMIT Policy N ❑ Certified copy is hereby furnished. l-, SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the co bu' ng insp on / COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Dotee///�'YApplicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING Qaom' i COMPENSATION INSURANCE ADDRESS ✓a��J '/ c�-T/ �" STATION � �t DEPTH (This section need not be completed if the work involved by the ` MANHOLE REFERENCE UPPER OWER permit is for one hundred dollars ($100)or less.) LOCALITY NEAREST TYPE OF CONNECTION LENGTH FROM Jit I certify that in the performance of the work for which this CROSS ST. CURB fit- M L TO P L ✓C' 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 NOdDATE 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 OIF �) revoked. BUILDINGS ��i�/ 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 BUST- MAIL -4:= CHARGES Hess and Professions Code, and my ADDRES license is in full force and �7 effect. / CITY�f . TEL.NO. CONNECTION CHARGE FEE License Number �,,r Lic. Class --5 a f REIMBURSEMENT FEE �/��YC.— Date le-� u Y — ! 7 CONTRACTOR��/��1�- DISTRICT NO GROUP MAP PROCESSED BY Contract �'l ADDRESS /J'�' r BK PG ❑ I am exempt under Sec. of the L.A. Co. /e�/ q�� 1p S,Q a p CITY 6�L/ TEL.NO. 6/ ZC y Plumbing Code and/or Sec. of the STATE LIC. /� FINAL U LICENSE NO. CLASS V r DATE (A_, / VALIDATION B. & P. Code for the following reason NO. DESCRIPTION OF WORK FEE -( It -1 Q 6 HOUSE SEWER CONNECTING TO FINAL - F. Date PUBLIC SEWER BY 0 SEPTIC TANK SEEPAGE PIT OR EJJ Signature PITS AND OR DRAINFIELD HOUSE SEWER CONNECTING TO N OWNER-BUILDER DECLARATION PRIVATE DISPOSAL SYSTEM ® Z 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 tEJ fessions Code): OVERFLOW SEEPAGE PIT, DRAINFIELD P_• & EXTN.CESSPOOL.DRYWELL.MANHOLE �..iS,:C i .4 ❑ I, as owner of thep p ro erry' y g as or m employees with wages ALTER.REPAIR OR ABANDON HOUSE "�'?'? their sole compensation, will do the work and the structure SEWER OR DISPOSAL SYSTEM 6.#,Ia-''_54'-• is not intended or offered for sale (Section 7044, Business +� and Professions Code). s i•EMSP ❑ 1, as owner of the property, am exclusively contracting with OWNERS Permit $ Z 7� 9I_IIhIL 66 - 53 licensed contractors to construct the project (Section 7044, Business and Professions Code). AUTHORIZATION TOTAL FEE S CNECl'' 6 .E5 CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CO�rRAcroR To ® { Ill I hereby affirm that there is a Construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER �.HANGE ae_ for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). SIGNED Tries DAY OF 19_ 00100-0100 y_�f� �� _ J[/ { OWNER OR I�0100�Ji03 j:7l310? Lender's Name OWNERS AGENT i �rj Z i Lender's Address ADDRESS Gi�C ifs Q na : 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 I s regularPlumbing and Sewers, and hereby author presen Iv of this County to enter upon the ve nti ty for inspection purposes. Signature o ermittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE