HomeMy Public PortalAbout5915-5927 OAK AVE_Sewer__ WORKERS COMPENSATION DECLARATION
I hereby offirfn that 1 have a certificate of consent to self
insdFv-&-B cgrtificate of Worker Compensation Insurance or 7GA02D
Fad Nodcompa y � �`°°�°P'"°'°° APPLICATION FOR PERMIT
❑tortified copy is hereby furnished SEWER - SEWAGE DISPOSAL
❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
depart nt ef
DateXApplicant FOR APPLICANT TO FILL IN CONNECTION DATA
RT ICATE OF EXEMPTION FROM W&RICERS BUILDING STATION
COMPENSATION INSURANCE ADDRESS JV/1 Al 49h, Nze.2
(This section need not be completed if the work involved by the LOCALITYMANHOUI REFERENCE
permit is for one hundred dollar(:100)or less) Leda K4&
NEARI cern that in the performance of the work for which this CROSS
TYPE URB
certify Pe CROSS SrS /7 Y CURB NECTION �TO PTH F L�
permit is issued (shall not employ any person in any manner PC NO
so as to become subject to the Worker Compensation Lows OWNER CO VAPNO JOB NO
MAIL TRUNK PERNIT NO ROAD PERMIT NO
Date Applicant ADDRESS q-AW
NOTICE TO APPLICANT If after making this Certificate of CITYAFFIDAv1r WAIVER FASEIIAEM RtCORD INSTR NO DATE
Af
Exemption you should become subject to the Worker LEGAL
Compensation provisions of the Labor code you must forthwith DESCRIPTION LOT NO HWY COST WIDENING
comply with such provisions or this permit shall be deemed
revoked BWgC TRACT STATE ENCROAcHmE T
PERMIT NO
LICENSED CONTRACTORS DECLARATION SIZE OF un Now ON BUD
GS
hereby affirm that I am licensed under provisions of Chapter USE OF
9 (commencing with Section 7000) of Division 3 of the Busi BUILDINGS CHAMES
ness and Professions Code and my license is in full force and L
CONNECTION a+AacE IS
effect aoNrRaCTOR
o
Ak
License Number �14-4Q NC Class ✓ ADDRESSO RE RSEAWNT FEE
Contractor 7 �nl��siain, 46at@6�=� l /717 CITY No �I/8-337 DISTRICT No GacuP BK MAP PG PROCESSED BY
❑ 1 am exempt under Sec of the L A Co
STATE NO LIC
r Q� a
Plumbing Code and/or Sec of the NO DESCRIPTION OF WORK FEE FINAL
HOUSE SEWER CONNECTING TO DATE VALIDATION
B &P Code for the following reason PUBLSEPTIC
SEEPA OR
Date PITS AND/OR ORMNF I FINAL
HOUSE SEWER CONNECTING TO By
SPOSAL SYSTEM
Signature N ADDITIONAL BNDG OR 10
OWNER BUILDER DECLARATION WORK TO HOUSE SEWER 0► � a
OVERFLOW SEDRAINFIEID T.
I hereby affirm that i am exempt from the Contractor s License EM CESSPOOL MANHOLE
Law for the following reason (Secton 7031 5 Buisness and Pro ALTER REPAIR OR ABANDON HOUSE � '� 34•
fessions Code) SEWER OR DISPOSAL SYSTEM
❑ I as owner of the property or my employees with wages as 1 ;TM
their sole compensation will do the work and the structure TOTAL 34••J❑
is not intended or offered for sale (Section 7044 Business Permit � 34.0
and Professions Code) OWNER'S
❑ I as owner of the property am exclusively contracting with AUTHORIZATION TOTAL FEE •LJcry�
licensed contractors to construct the project (Section 7044 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAME)CONTRACTOR TO �rtt'u�R�E i
Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWEtIING TO THE PUBLIC SEWER
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency SOVUIrEaoR IS �� DAY OF 19� ► -=I 12/17!94
for the performance of the work for which this permit is
issued(Sec SW CTI, C) 4534 1 PM120-51
Lender s Name ADDRESS—/1622,Z
Lender s Address
I certify that 1 have read this application and state that the
above information is correct 1 agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers t
and hereby authorize representatives of this County to enter
upon the above Menti nod property for inspection purposes
Signature of r Mee Date f SEE REVERSE FOR EXPLANATORY LANGUAGE