HomeMy Public PortalAbout9005 PENTLAND ST_Sewer__ WORKERS COMPENSATION DECLARATION
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byt°ffnm that I have a certificate of consent to self CII311
Insure or a,pertificate of Workers Compensation Insurance or 7EAMYD
. a� ` '7—,4 j—�— ®, APPLICATION FOR PERMIT
❑ Cer ified copy is hereby urnished SEWER - SEWAGE DISPOSAL
ertified copy is filed th the c my buildin Intion COUNTY OF LOS ANGELES BUILDING AND SAFETY
de rt n
Dat A hcaW FOR APPLICANT TO FILL IN CONNECTION DATA
CER FICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ADDRESS !
(This sect n need not be completed if the work Involved by the LOGALITr MANtgLE REFERENCE XI u
permit Is for one hundred dollars ($100)or less )
1 certify that in the performance of the work for which thisrc.a TYPE OF CONNECTION LENGTH FROM'
PL Mt Topt
permit a ensued shall not employ any parson m any manner
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so as to become subject to the Workers Compensation Laws �yL,RR GO IMP No T11� oe t
PSD IOLRE58 J WNT rJp ROAD PERMIT rJ0
NOTICE TO APPLICANT If after making this Certificate of TEL AFFIDAVIT WAIVER EASEMENT REcogo INSTR nq DATE
Date-Applicant
Exemption, you should became subject to the Workers IMAt
Compensation provisions of the Labor code you must forthwith DESCRIPTION LOT NO
comply with such provisions or this permit shall be deemed HM ORST WIDENING
revoked BLOCK TRACT STATE ENCROAWNT
NC)LICENSED CONTRACTORS DECLARATION ND of BLDG S RRMIT N
NOW
I hereby affirm that I am licensed under provisions SIZE OF LOT ON LOT
of Chapter
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is In full force and
effe CONTRACTOR ONNECTIO N CHARGE FEE
LI ns Flu���� Lic Class •� uRSEMENT FEE a
O ate L rS TRICT NO GROUP MAP FROCE BY
k.wO
n PG Z
ElI am exempt under Sec of the L A Co STATE
tip LIC 4 � �� O
Plumbing Code and/or Sec ~ of the NC) DESCRfPTION OF WORV FEE HNAL U
HOUSE SEWER CONNECTING i0 pgTE W
B 8 P Code for the following reason PUBLIC Se R VALIDATIO N
SEPTIC TANK SEEPAGE PIT OR HNAI 2
PITS AND/OR ORAINFIELD
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DlsFOSAL SYSTEM
Signature CONNECT ADDITIONAL&DG OR ,
OWNER-BUILDER DECLARATION WORK TO HOUSE SEVER
I hereby affirm that I am exempt from the Contractors License EEMNEL NFIEtO
�SEPt' E PIT DQYwE
EPaAGDLRAIAANHO E
Low for the fallowing reason (Secton 7031 5 Bwaness and Pro ALTER REPAIR OR ABANDON HOUSE
fessions Code) SEWER OR DISPOSAL SYSTEM
❑ I as owner of the property,or my employees with wages as
their sole compensation, will do the work and the structure 2059,6A
Is not intended or offered for sale (Section 7044 Business
and Professions Code) OWNERS Permit S S
# • • • •,10
❑ I as owner of the property am exclusively contracting with AUTHORIZATION TOTAL FEE
licensed contractors to construct the project (Section 7044 I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONT CrOR i0 1 •T• 2 7
5 0
Business and Professions Cede) CONNECT THE ABOVE DESCRIBED EXISTIIRG DWELLING TO THE Pu9LIC SEWER
CONSTRUCTION LENDING AGENCY • • • 2 7.5 0'
I hereby affirm that there Is a construction lending agency SIGNED THIS DAY OF 19_
for the performance of the work for which this permit Is OWNER OR
Issued (Sec 3097 Civ C )
OWNERS AGENT 0 902-88
ADDRESS
Lender s Name '
Lender s Address
j certify that I have read this application and state that the
above information Is correct I agree to comply with COunty
ordinances and State lows regulating Plumbing an $ewers
d-hQTsb9vuthonze representanves f
�tthis u t° er
a ihe abov ti
menoned ro or
Signature of Permilfbe Date SEE REVERSE FOR EXPLANATORY LANGUAGE