HomeMy Public PortalAbout6252 GOLDEN WEST AVE_Sewer__ 'i
WORKERS'COMPENSATION DECLARATION 78A842D
CE 808 (2-80) APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self SEY�F ERAS G DISPOSAL
indpre,or a certificate of Workers'Compensetibn Insurance,or
■certified copy thereof(Sec. 3800,Lab COUNTY OF LOS ANGELBUILDING AND SAFETY
C Po an
FOR APPLICANT TO FIVL IN CONNECTION DATA
Certified copy 4 herobyrnlahed. �—
1 Is ed with a county b )nspectioJA DRE■■ v BUILDING STATION v Di�rH
LOCALITY k G MANHOLE REFERENCE //� LOrER
Da Applicant ARS■T O TYPE OF ION LK 11
`ROY
CERTIFICATE OF EXEMPTION FROM WORKERS' OSS ST. /i< /�,� Y_ tole■ P.L. Y.L. TO`.L.
COMPENSATION INSURANCE 2 `.c, NO.
NER CO. IY`. No. V a- 701 NO.
/.�i� 7,,, y4L
\iuYby yyy ae�HOII IIOlBd riot ,.rp t1YM„v�_efJTrvIOJtEd�,,�ry}�t�fle t9/0�/u, iIIVbtVEDRa// TRUNK`<RYIT NO. ROAD `a:RYIT No.
Elle IIIc '1 for OIM LI11N1R3 LLUW■ ($1010) or I� A!`1 IvlT RANg1 ■Af�IT RECORD. IN.TR.RO.J. DAT. a
Y TEL. NO. jjjLVVViii]
I certify that In the performance of the work for which thLEGAL
permlt is issued, I shall not employ any person In any manne /artlrnoN L.O•r No. Huy, OR ■T. 1IDE ING
so as to•become subject to the Workers' Compensation LawOCK TRACT aTATR a:NCROACHYa:NT
Data . Applicant No. of ■L.DG/, risptb4lNo.
NOTICE TO APPLICANT: If, after making thls Certificate of slzE or Lqr N-OW 014LOT LU
Exemption, you should become subject to the Workers' u/E or ��--�”'
Compensation provisions of the Labor Code, you must forth- BUILD ds /GG d/ b wwaR■
with comply with such provisions or this permit shall be CONTRACTOR CONNECTION CHARGE FEE
deemed revoked. 3 Z/ . .1►� !LKImnuR/EMENT `"
LICENSED CONTRACTORS bECLARA'I'ION wDDRu/ 1�_
I hereby affirm that I am lice Rd under provisions of Chapter DI{TRIcY No. omouP MAP PRocE■{ED EY
■K ..
9 (,commencing000) of Dtrhion 3 of the Bual- crrY No, � �� i
neo and Professions Code, d y llCense L In full force and ucErFi No. cLw/■ �3 ZZ
effect._
NO. DESCRIPTION O`WORK rift ,
HOU■E■EVER CONN ECTINQ To FINAL ^ ` ' VALIPATION
License iNb!,i Lie.CLU Pu■LIC {taVER DATE
1E 1 TANK,{EEPAQ PIT OR
• DatO PIT{A../OR DRAINPIELD PINAL
Hou■E■EWER commacTINa
❑ PRIVATE DI{P0■AL SYSTEM TO my
I sm exempt from ilcensing regUBements as am a
coon ECT OUSElomAL■LO■,OR
licensed architect a registered professional engineer .oRN TO HOUSE ■E.tR
acting in my pro onai capacity (Section 7051, Bus- ov ERPi w{EEP,woE PIT,DRAINPIELD
mess and ProfalWo Code). EATN.,CE{{POOLI DnY*ELL,NANHOLE yf
ALTEIe, REPAIR OR A■ANDON HOU E
■twER ON DI PO{XL■Y■TEM
Lic.Or Reg.No. Data
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I ■m exempt from the Contractor's OWNER'S PerTnft f �Q
License Ltw for the following reason (Section 7031.5, Bwi- AUTHORIZATION TOTAL F E r1 f0
neo and Professions Code):
I HAVE AT THIS DATE A C'ONTRAGT 1 HEMEIN HAYS O
❑ I, at OWrlei Of the r0 TRACTOR TO CONNECT THE A■O E R D 9' n
property, wW d0 the work Red the TO THE ru■ut SEWER.
r1
structure b not intended or offered for sale coon '
616N�D THIS /\ OF .0
7044,Business and Profeations Code). o.NER OR
OSVNER■A67T ,
CONSTRUCTION LENDING AGENCY wooRE{■ r4/ 2'
22" 0
1 hereby affirm that there Is v construction lending agency
for the performance of the work for which this permit is i o 0 0 2 2 5 0>J
issued{Sec. 3097,Civ.C.). 1
Lender's Namp 0 4 2 7 i_8 2
Lender's Address '
1 certify that I have read this application and state that the
above Information is correct. I agree to comply with all Copnty
ordinance" and tate laws regulat robing nd Sewers,
and hereby n rite repraaentat of t Co ty to enter
upon the a entioned prop y pecti oMr.
SEE REVERSE' FOR EXPLANATORY LANGUAGE
Signature of Permittee Data