HomeMy Public PortalAbout9008 GARIBALDI AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self 2G-OW1 DPW&M
Insure, or a certlftcat•of Workers' Compensation Insurance, or
ert
o clfl thereof (Sec. 300
8 , b C., I APPLICATION FOR PERMIT
Policy•NI°iompany s t�
❑ Certlfled copy is hereby furnished. SEWER - SEWAGE DISPOSAL
❑ Certified copy Is filed with the county buflding Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
d• rtment. ,
Date ppllcant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICA OF EXEMPTION FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDSM Q� STATION °err"
(This section need not be completed if the work Involved by the MANWOE RUER&K2 UPPER
OM
permit Is for one hundred dollars ($100)or less.)
I certify that In the performance of the work for which thlt NCRO6s8 ST. TYPE Co�CURB oN M LENGTH P L
permit Is Issued, 1 shall not employ any penton In any manner r CURE r M L r0 P L
LEGAL' P{ NO
to as to become sub(ect to the Workers'Compensation Laws. UEBCAPTION IAT No. CO ALP NO Abe No
Dote Applicant BLOC( TRACT TRUNK TEZMYT NO 0.OADt'ERASfT NO
NOTICE TO APPLICANT: If, after making this Certificate of ►LAP PAGE 1!�5'1G PARC
EL dv� uMDAvtr wArvER EASEµEEHT RC{QRD wars P,10 DATE
Exemption, you .should -become spbject to the Workers' NO OF BLDG&
Compensation provisiont of the Labor code, you ritual forthwith eLZE OF LOT NOW ON LOT HWV OR Sr WIDENING
comply with such provisions or this permlt shall be deemed USE OF
revoked. BLALDIN138 STATE e+cROACH&IENT
LICENSED CONTRACTORS DECLARATION No
I hereby affirm that I am licensed ur)der provlslons of Chapter OWNER
9 (commencing with Section 7000) of Division 3 of the Buil- CxARGEs
ness and Professions Code, and m)l license Is In full force and
effect. It
CTEr TEL_NO. COCINECTtON CHARGE FEE
License Number I"L 9 e Lic.ClassREuwau T PEE
CONTRACTOR
]�
Contractor_[1�14r 1,s��41 Date G PROCESSED e
DrsTRICT NO GrtOUP AnAP r
ADOftEBE EK PG
❑ 1 am exempt under Sec. of the L.A.Co. pTY Od �� L
NO. SPlumbing Code and/or Sec, of the STATE
"°�No' CLAW DATE VALIDATION
z
B. d P. Code for the following reason NO, rtstoE+tc
HOUSE SEWER CONNECTLNG TO FWtA.L
Date PUEILK'SEWER 7-0 EV
tC TANK SEEPAGE PUT OR W
a
Signature Rrs g'r'ip CKt ow`i iEID �
-rOUSE SEw�R ING TO
OWNER-BUILDER DECLARATION �A oil I hereby affirm that I am exempt from the Contractor's License CONNECT BLDG DG OR. iV
Law for the following reason (Secton 7031,5, Buisness and Pro- WORK TO HOUSE SEWER
femions Code): OdERFIOw SEEPAGE PUT.DRAJ"LD ACCT.-Y'
EXTN CESSPOOL DR .MANHOLE
El 1,I,as owner pf the property,or my employees with wages as ALTER.REPAIR OR AEANOON 71.10
their sole
OR DISPOSAL SYSTEM le compensation, will do the work and the structure '
Is not Intended or offered for sale (Section 70", Business
and Professions Code). 1 ITEM
❑ I,as owner of the property, am exclusively contracting with O
WNER'S Permit = TOTAL. 71 - 10
licensed contractors to construct the project (Section 704", 71.1[
Business and Professions Code), ATION TOTAL FEE /p DECK
CONSTRUCTION L�IJDING AGENCY DATE A cor,rRACT wrtH rrtE NEREiN wvNED cONrRAcroR ro , .03
I hereby affirm that there ii a construction lending agency DESCRtEED EXISTING DWELLING TO TFE PUELIC SEWERfor the performance of the work for which this permit Is . (jDAYOF 19�Issued (Sec. 3097. Civ. C.).Lender's Name OR
OWNER OR
Lender's Address 6201 1 Ali 9.108
I certify that I have read this apoIlcatlon and state that the
above Information Is correct, I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers, .k
and hereby authorize representatives of this County to enter
upon the above-rnentloned property for In"ctlon purposes. r
S g—lureafP.rm, ee Date �J y SEE REVERSE FOR EXPLANATORY LANGUAGE
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