HomeMy Public PortalAbout6217 MUSCATEL AVE_Sewer__ %,Y,3RKF 'O.M4N'_,AT1ON DECLARATION
20-0051 DPW 6i8'i
1�hereby. affirm rho T i have a cerlifcote of consent to self
insure, or a cemicafe of Workers'Cornperisalion lnsu?arce-,or 76Afi42D
.a cerpfied copy mereof (SE.." '38CK) loth C
Parc
Pol c No Company, APPLICA14TION FOR PERMIT
l (�rlifed copy is hereby P furnished SEWER - SEWAGE bISPOSAL
I Certified copy is filed vvtth rhe county budding snsp[ctipn COUNTY OF LOS ANGELES BUILDING AND SAFETY
AppI,,any FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS, BUILDING
COMPENSATION INSURANCESIA-;( DEPTH
(This section need not be completed if the work involved by+he .E PEFFIZFNC�F PRE R
tow!Ep
permit is for one hundred dollars ($100) or less.) LOCALITY
NEAREST
TYPE OF CONNECTION
i cetify that in the performance of the work for which trisF.NG'i1 FROM
permit is ssued, I shall not employ any person in any manner CROSS ST. Y C�'RS P A,, 'C,P L
I LEGAL r);
so as to become subject to the Workers' Compensation Laws. LOT NO CO IMP NO NO
BL'0 C K TRACT TQuNK PERMIT NC) ROAD PERMIT NO
ASz,FSSOR AFF!,-,'AV?T SEN1,1EN- RECOR17) ;NSTR NO DATE
NOTICE TO APPLICANT If, offer making this Certificate of M4P_'F50OK IPAGIE
Exemption, you should become subject to the Workers" No GF:BLDG'; 1-7
CompensaTion provisions of the Labor code, you must f..)rthwoh SIZE OF L0. ON LOT HV.Y ',,,R ST WOFNING
comply with such provisions or this permit shall be deemed US-F OF
revoked. BOH DINGS STATE PICRC7ACHMFNT
PERWI NO
LICENSED CONTRACTORS DECLARATION OWNER
I hereby affirm that 1 am licensed under provisions of Chapter
9 (commencing with Section 7000) of Drv!sion 3 of the Su
�-_r4ARGFS
ness and Professions Code, and my'license is in full force oiI AUDFIESS
effect. rOr,,i-,Er71,0N CHARGE `EF
CITY 1 E L N U
License Number aLic Class_ REVB,�;6PAENT FEE
Contractor CONTRACTOR L6)_Y1':;IT )JA ,DisrpF NO GROUP MAP QED By
_ T 4n CRESS. 221k 0 /,AJ BK PG
I LL
-'I I am exempt under Sec -of the L A.Co. A,
C 0
V-2 P ii6
Plumbing Code and/or Sec., of the 5r rEV' I
AWN,:) DATE WDATION z
B & P. Code for the following reason NO. DESCRIP71ONCWWORK FEE
I N4,
Date SE41P 'Zo
Uj
SEPTI,-,TANK SHFAIE P!T OR
Signature- PIS AND OR C)RAINIFD
OWNER-BUILDER DECLARATION HOUSE SEwEk cONNE INPRIVATE D,SPQSAt 5STEM ► TOTAL -73 An
1 hereby affirm that I om exempt from. the Contractor's License 1`NECT ADn-MIDNAL 8 r);-_ -"PN �j
CK .
Low for the following reason (Secton 7031.5, Bwsness and Pro AORi(T-�OUSF SEWH� E 3 50
I-
fessions Code) VV iFIEJ)
RINEL, MANHOLE C H A N'(T J
i ALTER REPAIR OR ABANDON HOUSE
1, as owner of the property or my employees with.wages as !'E"VIR OR"ISPOSAL SYSTEM
their sole compensotion_ will do the work and the structure
is not intended or offered for sole (Section 7044, Business 00130-0-001 4/ '+",/96
and Professions Code).
I r "
1, as owner of the property. am exclusively�o 5`9 AM I ?
fS
licensed contractors to construct the prosect ISecon 7044, OWNER'S new lit $
Business and Professions Code). AUTHORIZATION TOTAL FEE
CONSTRUCTION LENDING AGENCY HA F AT THA A :_CNTPA( T�iE 'rERE 77-1 1)
I hereby affirm that there is a construction ending agency C_"��W_T THEA F,_'Nr
for the performance of the work for which This permit is
issued (Sec. 3097, Civ_ C sIcir-jED THIS---DAY Or 9
OR
Lender's Name OWNERS AGE N i
t E111111 RE�s
Lender's
I certify that I have read this application and state shot the
above information is correct. ! agree 10 COMPly With 011 County
o,dtriances and Stale law's regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upon !he above mentioned property for inspenon Durposes.
6�'
SEE REVERSE EOR FXPJ.ANATORY LANGUAGE
Signature of Ppirrint tee Dole