HomeMy Public PortalAbout5827 MUSCATEL AVE_Sewer__ WORKERS" COMPENSATION DECLARATION
I hereby affirm !hot I have a certificate of consent to self 20-0051 DPW 6189
ensure or a certificate of Workers' Compensation Insurance, !%t'
.� 76AB42D
a gar*$, copy thereof (Sec 38fb, lab APPLICATION FOR PERMIT
Policy NO
_Company_ Sc
Certified copy is hereby furnished EWER ' SEWAGE DISPOSAL
^] Certified copy is fled with the county budding inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department:.
Date Applicant_._ FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING _ N 'l y DEPTH snnOCOMPENSATION INSURANCE ADDRESS r
This section need not be completed if the work involved by the ,� r IJtp .
( p LO .MAl;HOLE REFERENCE _,. '�_�� d7 LOWER
permit is for one hundred dollars ($100) or less ) -
certif, that in the erformance of the work for Which this NEARESr TYPEOFGON iO ENGTHFROM
p CROSa ST. ` 9 ' Y r URS P L M L TO P l '�}�.f�.
permit is issued, I shall riot employ any person in any manner LeGST - PC No
so as to become subject to the Workers' Compensation Laws. DESCRIPTION LOT No Co IMP NO d z-) eB NO
BLOCK TRACT TRUNK PERMIT NO, ROAD PERMIT NO
Date =t/_, ' _ licant
NOTICE TO APPLICANT: If, after makg in this 900K
CertlfiCpte of ASSESSOR AFF'DAvit NAIVER EASEMENT RECORD iNSTP NO DATE
PAGE PARCEL
Exemption, you should become subject to the Workers' MAP Na E BLDGs
Compensation provisions of the labor code, you must forthwith SIZE OF LOT New ON LOT HWY OR ST WIDENING
comply with such prov:sion5 or this permit shall be deen'led USE OF
revoked. BUILDINGS STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION PERMIT No
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section. 7000) of Division 3 of the Busi- NAIL CHARGES
�f is Y
ness and Professions Code, and m¢license is in full force and ADDRESS
effect. ca -,-4r'6} CONNECTION CHARGE FEE
�y� CITY �� 0 ! (FL NO. s"`i rP
License Number 3e 9a4*LLic.Class " 4-� ^ f�
ii**`` _ LE�NiRACTOR �,� yo � EIMBl1R.StMENi PEE
Contractor Date
.t�,� i'� �`": ' IJ;SIRICT NO GROUP MAP PROCESSED BY
" ADD9E'�S � �r- T� ��d.?9�� BK PG
Dram exempt under Sec ._ ._of the LA. Co f y �� �' / 0-
Plumbing Code and,or Sec of the STATE LIC / Q
LICENSE NO pp CLASS „ATe c VALIDATION Z
B. & P. Code for the following reason_ NO. DESCRIPTION OF WORK FEE O
HOUSE SEWER C�."?NN T.NC,T<; �J FNAi. ,i
Date PUBLIC Sf WER A/// P�7 B, U
P
9 S A LANK SEEPAGE PIT CRR lL
Signature P SAN) A DRA';NFiEID 4.En
HOUSE SEWER CONNECTING TO —_ � Z
OWNERBUILDERDECLARATION PP.VA,E DISPOSAL SYSTEM —
I hereby affirm that I am exempt from the Contractor's License C aECT AD(',TONAL BLDG OR
Low for the following reason (Secton 7031.5, BllisneSs and Pro- NORK TO HOUSE SEWER
Cessions Code): CIERF.OW SEEPAGE'PIT.DRAINriELD
� EXTN CESSPOOIL DR1'WEU MANHOLE
Di I, as owner of the property, or my employees with wages as ALTER REPAIR CR ABANDON HOUSE
their sale compensation,, will da the work and the structure SEWER OR DISPOSAL SYSTEM
is not intended or offered for sale (Section 7644, Business
and Professions Code).
J I, as owner of the property, am exclusively contracting With
licensed contractors to construct the project (Section 7644, OWNER'S Permit $ t�! tfL-
Business and Professions Code), AUTHORIZATION FTOTAL FEE
CONSTRUCTION LENDING AGENCY I HAVE AT THIS ATE A CONTRACT WITH HE HEREIN NAME: NTRACT(OR rO
I hereby affirm that there is a COnStr'ilctian lending agency CONNECT THE ABOVE DES!kBfD f XiSTiNC, >-NEi LNC TO THF PUBLICSEWER
for the performance of the work for which this permit is
issued (Sec. 3097, Civ. C.), srGraFD THIS DAY OE—yam — 19
OWNER OR )
Lender's Name_ _ _ OWNERS AGENT
Lender's Address ADDRESS
I terrify 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 a -mentioned pr4[/�p�.rty for inspection purposes
Signotw4 of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE