HomeMy Public PortalAbout9312 OLIVE ST_Sewer__ WORKERS' COMPENSATION DECLARATiON
220-0051 L7PW 61$9
I `t`tret,^.iffirm that i. have a Certificate of consent to. self
i>'SSt. e. ur a ceri'tifi,ate ofWorkers' Compensation insurance, or ' 764642D
a cei crpx Cher (-Sec, 3f3Ot),,ttab APPLICATION FOR PERMIT
Po1,cyNa)li_�,���tr��r �Pany �t��-- � �t� � ���L� c
U Certified copy is hereby furnished. SEWER, - SEWACE DISPOSAL
Certified copy is filed with the county P,k.,"�ing inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
d pot menti.. ;' J
T
Dote _ _ 1 F. �Appliran FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' � EUILtiI F; i � l CEVT
COMPENSATION INSURANCE ADD+tE - l j'• i_;- ,,TLON
(This section need not be completed if the work involved by the r ANWDLEREFERENCE UPPER
permit is 'tar one hundred dollars ($100) or (ess acA Tv y LOWER
NF A-,RE ' t'P€OF CONNFCTION LENGTH FROM
1 certify that in the performance of the work for which this GRO 5 y CURB R 1 M� TO P1
permit is issued, I sholl not employ any person in any manner LEGAL PC NO
so as to become subject to the Workers' Cornpensatloo Laws, DFSCRiFTiON LOT NO C'D 1VP NO 108 NO
ApplicarTt_____:__..—____— __ I.
BLOCK TRACT ' .jNK PERMIT NO ROAD PERMIT NO
NOTICE TO APPLICANT: If, after making this Certificate of assEssc � AFF DAv'tt wA:vEa. EASEMENT RECORD IrdSTR NO DATE
g L1Aa BOOK I'AGE� �� PARCEL
Exemption, you should become subject to the Workers' r.O OF B;-GIGS
Compensation provisions of the Labor code; you must forthwith Si-E of t.,v_ NOIN ON LOT HW'v OR St WIDEN NG
comply with such provisions or this permit shall be deemed USE of _-
revoked. Built DINGS SLATE ENCRCA(7.HMENi
PERMIT Na
LICENSED CONTRAC'roRS DECLARATION --
i hereby affirm that I am licensed under provisions of Chapter
9 ;cornmencing with Section 7000) of Division 3 of the Busi- MAI: '3, L CHARGES
AnDRF..S
ness and Professions Code and my license is in fult force and
effect_ `� `� " 'NEC ON CHARGE�FEE
erTv Nom) ti 9 ': TEL No. � oy
License Number aLt1 Lic. Class_ � �-}f' RE+nauRSEMeN`FEe
y GO rtAc ToR L rv` _"'.
G"OUP MAP PROCESSED Br
Contractor DUte {" I i yt � 1 �, S_ ,1�.�, to ,l BK FG
}
!am exempt under Sec. _of the L.A.Co, AL�,EE
CIi'i �'`>, .a... 'i`7t EEL NO. L �..�:�.� „ / ��- :' -'d?.'�'a'yf"J�
a.
Plumbing Code and/or Sec., of the STATEy D IC T U
LICENSE NO '+ — -.,�.., ..> .�as(,.. "g - rrF" VALIDATION zz
B. & P. Code for the, following reason NO. DESCRIPTION OF WORK FEE 4`D
HOU,E SEWER CONNECTING,-p F.',AL
._ Date, .__ Pl�61.0 SEWER HY "` W
`EP.C TANK SEEPAGE PiT OR 0.
Signature_.___ lr�sAP..:D OR DRA:NF E1D 0
Hvv E SEWER CONNECTING TO � a: z
OWNER-BUILDER DECLARATION PRIVATE r SPCSA1:i STEM j, 3
i hereby affirm that I am exempt from the Contractor's License N NECT ADD T:ONAi BIDU OR _
Low for the following reason (Seetbn 703'1.5, Buisness and Pro- WORK TO HnJ$E SEWER
fessions C VE RF OW SEEPA,F P r DRA:NIE D
Ude)' N 'FSSE OCDL. DRYWEI4 MAN HC9I,E "7,Tt 1"' •'�fi >..'
[-1 n
J I, as owner of the property, Of my employees with wages as AL ERR RE A R OR ASAPDUN HOUSE
`a o.,PGSA:Svo�EM
their sole compensation, will do the work and the stru ,EwE
cture
is not intended or offered for sole (Section 7044, Blasiness
and Professions Code).
I, as owner of the property. am exclusively crsntro_linq With OWNER'S Permit $
licensed contractors to construct the project ;Section ?044,
Business and Professions Code). AUTHORIZATION TOTAL FEE y? IIS. of
CONSTRUCTION LENDING AGENCY I HAVE AT THit 'DATE A t_ TRACT WTiI THE HtREir NA rt NTR1 rJR rCa
hereby affirm 'hat there is o :anstrijction lend ng agency ',)NNEC.'.'THE ABOVE To T',ae PiLLL-SEWER
for the performance of the work for which This permit i5 � y��t t0-111-000 t �t 1;:,
slued (Sec. 3097, C,v. C.L CNFD THIS DAT OF t9_
i'VO4EP OP
Lender's Name---- -- -- --- — OW'NERSAGENT_ _—___--.
�� A�rREss
Lender's Address^------------------- _ -----_—_..__�.� -
I certify that t have read this application and state that the
above information is(,orrect. i agree to comply with all County
ordinances and State laws regul;]ting Plumbing and Sewers,
and hereby authorizeentatives of this (County to enter
upon the above-m i`t,oned p opert,n,for inspection purposes.
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE