HomeMy Public PortalAbout9002 GARIBALDI AVE_Sewer__ WORKERS' COMPENSATION DKLARATION
I hereby affirm that I have a tertiflcata- of consent to self 20-DDB1 DPW BI80
insure, or a cerlificate of Workers' Compensation Insurance,or 7L4E42D
a certifi co ther of (Sec. Lab ) I� APPLICATION FOR PERMIT
Policy No. ampan
❑ 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 jriment.
Date Appllcant LFOR APPLICANT T4 FILL IN CONNECTION DATA
CERTIFICA OF EXEMPTION FROM WORKERS' BLrLDuq
COMPENSATION INSURANCE ADDFIEes STATION DEPTH
(This section need not be completed If the work Involy theMANFIOLE �� JPPER
LOCperr'nit It for one hundrbd dollars ($100)or less.) NEAREST
L
OM
I certify that'in the performance of the work for which this Y TrPE Cf CONr[-CTION TO L
permit is Issued, 1 shall not employ any person'In any manner cL CURB o L M M L L TOP L
a c No
so at to become subject to the Workers'Compensatlon Laws. oEE�a� pTpN LOT NO
CO WW NO lob NO
Data Applicant BLOCK TRACT TsvN,c PERMIT NO Row PERMT NO
AFFIDAV T ArvER EASEhAENT RECORD IrrsTR NO DATE
NOTICE TO APPLICANT: Lf, after making this Certrfttate of taAPAtsE PAOEQ1G w
fxempuon, you should become subject to the Workers' PAAC�L
110.OF BLDQ&
-a mpentation provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT HWY OR ST WIDENING
comply with such provisions or this pbrcnit shall be deemed UBE OF
revoked. BUILDI1408 STATE ENCROA.C1-MM
LICENSED CONTRACTORS DECLARATION PERMIT NO
I hereby dfflrm that I amlicensed Under provisions of Chapter OWNER ` w
9 (commencing with Section 7000) of Division 3 of the Busl- "L
ness and Profession% Code, and my Ilcbnse is rn full force and w � CHARGES
effect- CITY TEL No. CONNECTION CHARGE FEE
'Ida
Licensember Lic.Clans NT Fig
CONTFIACiOR
Contractor ��0p&d Date DtSTA ICT HD P MAP PROCOWD BY
* ADDFfE.98 { ` tic PG
❑'Iamexempt under Sec. oftheL,A.Co. rr�0JJ�
2crrYEd" No. .✓
Plumbing Code and/or Sec. of the STATEuc FINAL
''C�ENSE NO OLA88 DATE VALIDATION
B. $ P. Cod• for the following reason No. N of WORK FEE _ Z
- O
HOUSE SEWER CONNECtING TOPINKDate PUBLIC SkWER BY
SEPTIC TAN& SEEPAGE PIT OR
Signature PTS AND CriDRAJNFIELD
OWNER-BUILDER DECLHCKJM SEWER CONNECTING TO
PRN
ARATION , 10
ATE D Y
I hereby affirm that I am exempt frotn the Contractor's License CONNECT ADDITx:x LA1 BLDG 8-Q-
Law for the following reason (Secton 7031.5, Buisness and Pro' WORK TO HOUSE SEWER
` T�T
fesslons Code): OJERt30W SEEPAGE PIT,DRAINFIELD ��.��
EX7N.CESSPOOL.DRYWEIt.MANHOLE
❑ 1,as QWner of the property, Or my employees with wages as ALTER,REPAIR OR ABANDON HOUSE
;
their wlp compensation, will do the work and the structure SEWER OR DISIK)W SYSTEM ITEC
is not Intended or offered for salb (Section 70aa, Business
j
and Professlons Code). TOTAL 71 - 10
❑ I,as owner of the property,am exclusively controcting with OWNERS Permit ; `jj p { 71,iC►
licensed contractors to construct rhe project (Section 7044,
BDslness and Professions Code). ALFTHORIZATION TOTAL FEE .0
CONSTRUCTION LENDING AGENCY J HAVE AT THrs DAVE A CONTRACT WITH THE HEREIN NAMED T OR TO ,
I hereby affirm that there Is a construction lending agency CC)tP*C'T THE ABOVE DESCRIBED EXISTING DWELLING t0 THE PUBLIC SEWER
for the performante of the work for which this permit is iyyy �ryi 7fr�4
Iss4ed (Sec. 3097, Civ. C.). SIGTJEDTNIS DAY'OF 19 L�J��Ny�N� �y� �}p
OWNIER OR
Lender'% Nome OWNERS AGENT 5199 1 ASI 9-W
tender's Address
ADDRESS
I tertlfy that I have reed 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 representatives of this County to enter
upon the above-mentloned property for inspection purposes.
�T
7NS,gngture of Permittee Date SEF REVERSE FOR EXPLANATORY LANGl1AGE