HomeMy Public PortalAbout9050 GARIBALDI AVE_Sewer__ WORKERS' COMPENSATION DECLARATION 1
I {tereby i5fft0 that I hove a certlficote of consent to self ��T�N E199
Insure, or a cert ffcotp of Wc4ers'Compensation Insurance, or i
a Certifytd'�opy tkereof ISIS-c.38WIAPPLICATION FOR PERMIT
Pio No' Company �}k SEWER - SEWAGE DISPO AL
❑ Certified copy Is hereby furnished.
❑ Certified copy is filed with the cos ding Inspection COUNTY OF LOS ANGELES BUILD NG AND SAFETY
department.
Date 1-?QaY Appllcan FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ADOFtE�B Q, L ' �'AT1ON
(This section need not be completed if the work Involved by the LOCALITY �� �, Cz MAN.CIE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.)
NEAREEITTYPE OF CONNFCIION LENGTH FROM
I certify that In the perOat ST of the work for which this Oa8T. Y Curet P L M L TO P L
permit Is issued, 1 shall not employ any person In any manner i m. PC No
so as to become subtect to the WorkersCompensation Laws, DEBOMPTION LAT NO, CO LW NO JOB NO
BLCK OTRACT TRUM PFRAVT NO ROAD PERMIT NO
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of taAPAes�a / 7� PAOE Q/ PAT>�/� A"IDAVIT WATVER EASEMENT RECORD INSTR NO DATE
Exemption, you should become subject to the Workers'
NO.OF BLDG&
Compensation provisions of the Lobar code, you must forthwith Big OF LAT NOW ON LOT HWY OR ST WIDEN NG
comply with such provisions or this permit shall be deemed USE OF
revoked. ElUILDIN08 STATE ENCROA 3VAENT
LICENSED CONTRACTORS DECLARATION PERM NO
I hereby affirm that I am licensed under provisions of Chapter OWNER
9 (commencing with Section 7000) of Division 3 of the Busl- WuL CHARGES
ness and Professions Code, and my license Is In full force and ADDRM
effect, — CCX4 ECTN CHARGE FEE
TEL NO. IO
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License Number 3 Lic.Class --7)(,
17)�C� FH I
COnhaCtO Date ` .7`-'- ` CONTPIACTOflk�KDrSTRICT No GROUP MAP •�3JCfdSED BY
ADDRESS W, 1 Cil 6x PG 1r t
❑ 1 am exempt under Sec. of the LA.Co, F T" l _ 5
- �' n Gl
Plumbing.Code and/or Sec. of the STATE CF No. LIC.CLAaSC— (s DATE V = .
B. d P. Code for the following reason No. DEaatLtPriow OF wok FEE 72
Date I SEWER CONNECTING TO EPNµ ` •i
SEPTIC TAN( SEEPAC�f PIT OR
Signature PITS AND OR DRAItF¢1D
OWNER-BUILDER DECLARATION HOUSE SEWER CONI ECTi1G TO , l r'•,�
PRIVATE d
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- WO'RX TO HOUSE SEWER
EXTN.CESSPOOL.DRYWI.MA1yy b� ,y��J
BROW SEEPAGE PR DRAtNFrRD
ELNHOLE
fesalOnS Code): a
❑ I,as owner of the property, or my employees with wages as �.Rf a OR'���M �7 �j: �
their sole componsotlon, will do the work and the structure
Is not intended or offered for sale (Section 70x•1, Business
and professions Code).
❑ I as owner of the property, am exclusively contracting with
licensed contractors to construct the protect (Section 7044,
OWNER'S Permit t 6
Business and Professions Code). AUTHORIZATION TOTAL FEE
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CNTRACTOR TO ,
I hereby affirm that there Is a construction lending agency CONFECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER
for the performance of the work for which this permit is
Issued (Sec. 3097, Civ. ) Se'NED THIS DAY OF 19
{� p
OWNER OR
Lender's NONTERS AGENT_
Lender's Address ADDRESS
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 laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upon the obov - tioned property for Inspection purposes.
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE