HomeMy Public PortalAbout6247 GOLDEN WEST AVE_Sewer__ pWORKERS' COMPENSATION DECLARATION.
hereby affirm that I have a certificate of consent To self 2&"l DPW EIM
insure, ora certificate of Workers'Compensation Insurance, or 7BA642D
.c h re f (Sec. 3800, La , APPLICATION FOR PERMIT
P company
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Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
[ u.ertif�ed opy+ls filed with th county bul Ing inspecti COUNTY OF LOS ANGELES bU1LDING ANQ'SAFE�1f
de rt
Date Applicant FOR APPLI NT TO FILL IN G0NNWn0N DATA
ERTIFICATE OF EXEMPTION FROM WORKERS' WLDqWSrATON / O
COMPENSATION INSURANCE AnDrt>se !�. TH
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(This section need not be completed if the work Involved by the MANFXXE REFERENC
permit Is for one hundred dollars ($100)or less,) LOCALrIrrY
I certifythat in the performance of the work for which this NEAt 6T TYPE of c roN LENGTH FROM
Pe CFlO96 Br. r r t M L ro P L
Permit Is issued, 1 shall not employ any,person In any manner LEGAL D r NO
so rn to become subject to the Workers'Compensation Laws. DEi6CIEvrx N LOT NO. CO µtip NIS )Oe NO .
Date Applicant BLOCK TRACT TRUNK PERMIT Na ROAD PERAVT NO
ASSESSOR INOTICE TO 74PPLICANT' If, after making this Certificate Of ASSESSOR PAGE PARCEL AffpAVIT WANER EASEMENT RECORD NSTR !J DATE
Exemption, you should become tubject to -the Workers' No di`BLOW.
Compensation provisions of the Labor code, yoy must fotthwlth SLZE OF LOT NOW ON LOT HWY OR ST WIDENING
comply with such provislont or this permit shall be deerhed USE OF
revoked. BUILDINa3 STATE ENX3roACHA%ENT
LICENSED CONTRACTORS DECLARATION PERMIT No
I hereby offfrm that I am Itcensed under provisions of Chqpter OVINE
9 (commencing with Section 7000}of Division 3 of the Busl- t+AJA r p� ,Es
nest and Professions Code, and ray,license Is In full force and
effect, Rz
t�ION CHARGE FEE
License N r /& Lic.Class -/10 *a(-- REIMaLW4EWNJ FEE
coNTFeAcro6
Contract Date _ DISTRICT NO GROUPS MAP PROBY
AK PG
QI any exempt under Sec. of the LA.Co. /,� – 7j
r ' lJ
Plumbing Code and/or Sec. of the STATE LJC. r AE
LTCEitaE NO, CL,ABs t DATE VALIDATION
B. 8 P. Code for the fol-lowing reason NO. DeSCRIP-WIN OF WORK FEE —/a '9 Z
O
HOUSE ISEWER CONNECTING TO FINAL
Date P^OC SEWER BY }}rr
SEPTIC TANK SEEPAGE P'T OR (LU
Signature P'TS AND.OR DRAINFCD , Z
OWNER-BUILDER DECLARATION HOUSE$EWER CorraEL TW_TO
PRrVATf Dr sr
I hereby affirm that I am exempt from the Contractor's Glcense CQt n ADDMONK BLDG OR
Law for the following reason (Secton 7031.5, Bulsness and Pro- WORX TO SEWER ' . 10
fessions Code): OVERFLOWSEEPAGE ?—
❑ I,as owner of the property, or my employees with-wages as '4TER.�P'U"C'
E�Np(X�'b l T■T
SEWER OR DI5r5TEM �
their sole compensation, will do the work and the structure r�9�,30
Is not intended or offered for sole (Sectlon 7044, Business
and Professions Code). l 1 ITM
Q I, as owner of the property, am exclusively contracting with WNER S Permit : TOTAL
licensed contractors to construct the project (Section 7044, Q
59 . 30
Business qnd Professions Code). AUTHORIZATION FTOTAL FEE GECK 59.W
CONSTRUCTION LENDING AGENCY I HAVE AT'TKS DATE A CONTRACT W'TH THE HEREIN NAMED TRACTOR TO ,
I hereby affirm that there Is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLW.G TO THE PUBLIC SEWER — CA*u - W
OWNER OR
for the performance of the work for which this permit Is
issued (Sec. 3097, Civ- C.). SIGNED THIS DAY Of 19_ f(''Wy'yS}f�L_ryryyy1y ..1!O
Lender's Name O'WNIE AGENT Lpp�JLppMp–MI 3/10/93P
�},}/10 7L3#
Lender's .35n 1 ,AM11:44
1 t t I +IbYe read this Ilaatlon and state that the
a ve Information Is correctq,4nl'
I to comply with all County
o nces and State lawT umbinq and Sewers,
and he y aulhorlxe reaes o this County to enter
ve-mentioned f ctlon purpose .
Signat o rmltt Dote SEE REVERSE FQREXPLAPtATORY LANGUACE