HomeMy Public PortalAbout10619 OLIVE ST_Sewer__ WORKERS' COMPENSATION DECLARATION
I hereby affirm that I hove a cer?,ticate of consent to sett 76A641 DPW 6189 u
Insure, or c,F certi icate of Workers Compensation Insurance, i) 75AF42D -
a'certlfjed cop t ,,(secs , Lop _ -^ _-- ' APPLICATICIIII FOR PERMIT
Policy F! __r Company_
�` Certifled copy Is hereby furnished SEWER - SEWAGE DISPOSAL. F
. 1. Certified Capy is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
deprartment,
Applicant_ -= c =�—' — FOR APPLICANT TO FILL IN CONNECTION DATA •
CERTIFICATE OF EXEMPTION FROM WORKERS' nUIL ,NG j.` STATION DEPTH
COMPENSATION INSURANCE ADDRESS �. Z L
u
(This section need not be completed,f the work involved by the -- M.ANHOEE RFFESENCE UPPER
Permit is for one hundred dollars ($1700)or less ) Lc)c"`TY (, ,�. t-z' _ (OWER
NEAREST > T"-PE CE CONNE.lip"J .ENGTH FROM
I certify !hot In the performance of the work for which this CROSS Si Y 5JRE, P! M, TeaP(
permit is issued, I shall not employ any person in any manner
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so as to become subject to the Workers'Compensation Laws- DEc;aIPnON I_oT NO. co IMP NO Uo6 NO
E CCK TRACT TRUNK PERMIT NO ROAD PERWT NO
Date,
NOTICE TO APPLICANT' If, offer making !his Certificate of MAP BOOK q/�� /p_ ^! p� � AFFIDAVIT WAIVER EASEMENT, RECORD INSTR NO DATE
MAP F30QW Clw��[f'' PAGEG' ..J C��' pAF?CEL C-:� �
Exemption, you should become Subject to the Workers' NO O,, I DOS
Compensation provisions of the Labo"code. you must forthwith SIZE OF I.C`r NO'N ON tC' HWY OR ST W!9f Ni.NG
comply with such provisions or this per+<tit shall be deemed OSEut
revoked. EsUtE.DI NCS STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION ` P€R:M T NO
I hereby offirm that I am licensed under provisions of Chapter o✓vNER h`'"(t
9 (commencing with Section 70(00) of Division 3 of the Bus,- MAI' - —
ADDRESS CHARGES
ries', and Professions Code, and my'license is in full force and
effect. CITY TEL NO CONNECTION CHARGE.FEE -
License Number a j Lic. Class RE:MEURSEMENT FEE
f
Contractor" s t' i _Dote sTR cT Nc GRoue MRP PROCESSED eY
ADDRFSS
EIK Fri,
�� I am exempt under Sec. of the L.A.Co -js s K } O
CITY _ 1 CI f�'/er{`� TEL No. !r ._ r(€5:> B
PlumbingCode and. or Sec of the STATE EIC FINAL 0
--.---- E r ENISE N +: r t7C d 0LA,^ 6 i, tr, DATE VALIDATION
. 7
B. & P Code for the following reason, ND. DESCRIPTION OF woaN FEEp
H u r ScV� R--,^�rvT ^i C;TC / F!NR,
�.� Datec,Ev FR 6t �'`? r,Y
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P r TANK SEEPAGE Pl OR
Signature--_ _ is AND CIR CRAINF£
OWNER BUILDER DECLARATION HOUSE SEW`k` NNEC NCz
R A'D SPSA SY,FM _ ,i;.I 9
hereby affirm that ! am exempt from me Contractor's License or EtT ADC IT JNA wI,I> <, _._
Law for rhe following reason %Secton 71131.5. Buisness and Pro- WORK TO Ho USE SEWER _
OVERFLOW SEEPAGE PIT DRAINP.iECC,. r
fessions Code) EXTN C=ESSPOOL. DRYWFu MANHQi1
. REPA
J I,as owner of rn
f the property, or my ecicAER. rr AEAND,N t4(,)USE
yees with wages as S,�
their sole compensation, will do the work and the structure
SEWER oR SAL SYSTEM
is not intenders or offered for sole 'Section 7044, Business
and Professions Code)
L_J 1, as owner of the property, am exclusively contracting with OWNERS Permit $
licensed contractor$ to construct the project (Section 7044
Business and Professions Code). AUTHORIZATION TOTAL FEE "~ "`'I
CONSTRUCTION LENDING AGENCY I I<AVF AT TH'S IAIF A (CINTkA(r w HEk£ti NAMTZ, f__,Nl'iACT0R
I hereby affirm !hot there is a constr.action lending agency _IONNE_ E an,'lt CESCR,aE„cKISTIN %E,kHF Pat SE.li:k
for the performance of the work for which this permits
issued
t t�EL H74 r
issued (Sec. 3097, Civ C.) _ U - DRY cD7 Lam_ 9t j'
OWNER C d
Lender's Name_ _ —� OWNERS AGENT
DDRESSjl,t
Lender's Address—____
I certify that I hove read this afpl cation and state that the
above informr.tlon is correct I F,yree to comply with oil County
ordinances and State lows r�#iTulattng plumbing and Sewers,
--=find het�by authorize rep sen+:atives o' th;S County to ente.-
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upon th, above menhono property for Inspection purposes.
'.Igndiure of Per Itfee �'' —�~ Vate - SEE REVERSE FOR EXPLANATORY LANGUAGE