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HomeMy Public PortalAbout5941 MUSCATEL AVE_Sewer__ WORKERS'COMPENSATION DECLARATION ,;,.hereby affirm that 1 have a certificate of consent to self 26AS42 DRW 8ft39 ensure., or.o certif.Icate 07 Wor,lSers'Cp.mpensatton Insurance, or. 76A842U ,a �eftlf d cj y ereaf 'S. E00, C ),� ,�-.. APPLICATION F PERMIT PoI,Ly No rt, yj, h U Cerlafied copy'is hereby. furnished SEWERSE.p�p/ AGE DISPOSAL L;. Certified copy is filed with the county building ins'peoion COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Dole/ ApPficont .x� � y FOR APPLICANT TO FILL IN t CONNECTION DATA. CERTIFICATE OF EXEMPTION FROM WORkFRS` BUILO+NrA COMPENSATION INSURANCE AOMESs. 5 I 09I,r Cf!1794- sTATIOry DEPTH (This section need not be compl.esocl if the work involved by thev bWNHOCF REFERENCE UPPER permit is for one hundred dollars.($100)or lessCl :.} LOCALITY r�"" LOWER NEAREST IY.PE OF CgNNECTIOIN .LEN..a.TH.FROM 1 c'erttfy tho+ In the perf.ii,manc•e :of .the work for which -.t€is GROSS ST. IZ y /ii Y CURB Pt ML To'P L permit.rs.issued. 1 shall not'employ any person In any:manner LEGAL PC NO so as to become subject to the Workers'Compensation Laws DESCRIPTION LOT NO CO IMP'NO JOB No BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO Qat@ Applicant � ASSESSOR r� /' 7•7 AFFIDAVIL WAIVER EASEMENT RECORD INSTR NO DATE NOTICE. TO APPLICANT. If, after making this Certificate of MAPSOOK •, 7. 4' PA©E /r PAR.GtiL'/ 1 Exemption, youshould become svbl.ect to the ftekear NO OFOLDGS Compensation provisions of the Labor Cade,you must forthwith SIZE OF LOT NOW ON LOT HWY OR ST WIDENING comply with such provisions or this. permit .shall be deemed USE OF rJ„ revoked. BUILDINGS a'C.-if t/ .i. t" STATE ENCROACHMENT PERMrT'NO LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under. provisions of Chapter OWNER 9 (Commencing .with Section 7000) of .Division 3 of the Bu si- ^TAIL ,g CHARGES n..ess and Profess'Pons Code, and mV license.ism full force and effect. CITY TEL NO.. CONNECTION CHARGE FEE .License Number&: �9i Lic-Class �✓~ Nr REIMBURSEMENT FEE C r CONTRACTOR, ( � �, /Y DISTR.CT NO GROUP MAP PROCESSED ev ConfroctoCX?_!k, &.2NT Dole ADDRESS �/���y� ¢ Br. PG arta.e ' ❑ I xempt vender Sae: of the i A.Co. CITY G� +4 T.EL.NO. °�' ` �'r7 ,f` dd e ft%� p Plumbing Code and/or Sec.- Of'the ` STATE — -+ � uC. F,NAL U 4S,� ,T5� LICENSE NO CLAss VALIDATION O B; & P. Code'for the following reason NO. DESCRIPTION OF WORK FEE '-117)-c r,%SE SEWE4 CONNFC'ING TO ,,��'' FINAL 1-• Date K BvC SEWER "r,'�y* By ASEPTIC TANK PAGE PII OR }� Pitt AND OR DRAINFIEID SlgnafUre ® iQ>� Jok HOUSE SEWER CONNECTING TO y OWNER-BUILDER:.DECLARATION PRIYATF DISPOSAL SYSTEM f ITEMS I hereby affirm that 1 oral.exempt;from the.Contractor%License COrvi'l ADDITIONAL SLOG OR LOW for the following reason.(Secton 7031.'5, Bulsness and.Prow WORK Ta 14OUSE SEWER TOTAL a� � 'feSsrans Code.)• OVERFLOW'SEEPAGE PIT DRAINF-tL ' ExT'N CESSPC)OL DRYWELL MANHOLE [3R. I.. I,as owner of the.propeft.y,or-My etnploye.es'with wages as At TER. REPAIR�OR ABANWN HOUSEMEN 73_3C SEWER OR'DISPMAI SYSTEM their safe compensation will.do the work and the structure e0 is not intended or offered for sale (Section 7044., Business I- and Professions Code), L 1 1,os owner of the property, am exclusivelycontrocting with OWNER'S permit g 6000-0001 �� licensed contractors to construct the project (Section 7044, 3/96 Business and Professions Code). AUTHORIZATIONTOTAL FEE: 4066 1 PM 12 2.9 CONSTRUCTION LENDING AGENCY I HAVE At TW5,WE A CONTRACT WITH THE HEREIN NAMED C!INTRACTO2 TO I hereby affirm that there Is a construction lending agency ONNECi THE ABOVE DES.CR BFD EXISIING.D&ELUNG TQ THF PUB,.IC SEWER for the performance of the Work. for which this permit .Is. issued ($e.c'. 3097, Civ, C ) SIC+TED THI'S DAY't)F, 19� E"hn1ER OK Lender's Name OWNERS AGENT Lender's Address _____ ADDRESS 1 certify that I have read this application and state that the above Inforrttotio.ri is correct .I agree to comply with all County ordlnonces ati and State. lows regulng Pl.u.m.'bingotid $ewers, and hereby outhoraze representa.tives .of this County to enter upon thevb oned property for.inspeCtion purposes. Signature of,P rm.irte Date r SEE REVERSE FOR EXPLANATORY LANGUAGE