HomeMy Public PortalAbout9000 GARIBALDI AVE_Sewer__ WORKER$' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self 2[H0061 DPW 61BD
Insure, or a certificate of Workers' Compensation Insurance, or 7E.A8s2D
a certified copy theyf (Sec. 3800 Lab ., 1 APPLICATION FORPERMII`
PoIISyT, -1ZL_Lompany
❑ Certified copy Is hereby furnished. SEWER - SEWAGE DISPOSAL
❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
de rtment.
Date L Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPfION FROM WORKERS' BUIMNG
COMPENSATION INSURANCE ADORE91B DD O STAhGN DEPTH
(This se,tlon need not be completed If the work involved by 7e 1
MANHCX.E I�PV,;CE UPPER
permit is far one hundred dollars ($1.00)or leu.) LOCALITY
I certify that In the performance of the work for which this Ct Y OWER
NEAFtEST
TYPE OFCOE+FCTIDH FROAL
L
permit is Issued, 1 shall not employ any Tmrson.in any manner CURB P L tii o P L
LEGAL
so as to become subject to the WorkersCompensation Laws. DEBCPTTON LOT NO. qO IMp NG Joe NO
Date Applicant BLOCK TRACT TRUN(-ERMIT NO ROAD PERMIT NO
NOTICE TO APPLICANT: If, after making this Certificgte of ARApA88E�BaoR PAGE D/�o ��vT wATVER E.ASEMkW RECORD INSTR No DATE
Exemption, you should become aubjeSt to the Workers'
NO.OF al-DOS.
Compensatlon provisions of the Labor code, you must forthwith ✓ZE OF Lot NOW ON LOT HWY CQST WIDEt,{ING
comply with such provistons or this permit shall be deemed bBE of
revoked. BU I LDR NG8 STATE ANT
LICENSED CONTRACTORS DECLARATION SRM T No
I hereby affirm that I am llconsed under provisions of Chapter OWN ER s �'
9 (commencing with Sectron 7000) of DIVI}ion 3 of the Bust- µAILt' aiARGEs
nems and Professions Code, and m�+ license is In full force and ADORESe
effect. CITY CONNECTRON C ARGE FEE
License Number Llc.Clam 1 FEE
CO NTTV,GTOR Q"
Contractor Date G DISTRKr NO GROLlr MK)U SED BY
ADDRE86 - SK PG
❑ I am exempt under Sec. of the L.A-Co. �3
crry TEL'., ^
PIumbiIng Cc-do and/or Sec. of the STATE FNAL 4C31
UCENSEN0. CLASS DATE VALIDATION Z
B. $ P. Code for the following reason no. I DEOCkPT100M OF WORK Fff
HOUSE SEWER COt V4FCTING TOkLNAL
Date PUNLRC SEWER O BY
. PTIC TANK SEEPAGE AT OR J
Signature PITS AND OR DRAIlNFIE-LD 1
HOUSE SEWER CONNECTING TO
OWNER•BUILD�R DECLARA710N pRrVATt , .�+ i Z_
I hereby affirm that I am exempt from the Contractor's License CONNECT ADDIT r OR �tR•CT.'r
Law for The following reason (Secton 7031.$, Bulsness and Pro- wOax T HarsE SEWER 71.10
OVERFLOW SEEPAGE PIT.DRAJNWELD
fesslont Code): E N CESSPOOL DRYWELL.MANHOLE 1 T
❑ I, as owner of the property, or my employees with wages as ALTER.REPAIR OR HOUSE 1
SEWER OR DISPOSAL SYSTEM 7 1_ 1G
their sole compensation, wtil do the work and the structure T�T�
Is not intended or offered for sole (Section 70", Business
and Professions Code). 71.W
❑ I, as owner of the property, am exclusively controctirlg with
licensed cohtractors to cehstruct the project (Section 7044, OWNER'S Permit $ o (A*GE ,.00
Business and professions Code). AUTHORIZATION TOTAL FEE ' 1/ 10 t
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WTH TFf HEREIN NAMED tQ0NTRACT0Q TO ,
I hereby affirm that there Is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DVdLLING TO THE PU6LIC SEWER 1 7/25/94
for the performance of the work for which thra permit Is [ �1
issued (Sec. 3097, Civ. C.). SIGNED DAY OF 191 QU 1 AM { - Q
OWNER OR e
Lender's Name OWNERS AGENT
Lender's Address ADDRESS
I certify that I have read this application and state that the b
above information Is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter.
upon the above-mentloned property for inspection purposes.
gnaturo o Permittee Date S#E WVERSE FOA EXPLANATORY LANGUAGE