HomeMy Public PortalAbout6026 PRIMROSE AVE_Sewer__ WORKERS' COMPENSATION DECLARAT!Otr �j
20-0051 DPW 6189
I here4Jy affirm'that 1 hove a certificate of consent to self `JJ
Insure, or 6 rtificate of Workers"Compemasation Irnsuronce, or 76A642D
a e;rifled cagy thereof (sec. 3800 ti . Lab C , APPLICATION FOR PERMIT
Pr;i„_y No.__.__—__Company._ __._.----
T Certified copy is hereby furnished SEWER - SEWAGE DISPOSAL
l- Certified copy ;s filed with the county bui';dinq inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Date__ Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' EullDn� ! c«� STAT ON DPPTH
COMPENSATION INSURANCE noxa S >`,,G,. f'f�. r' �'� '/i
(This section need not be completed if the work involved by the LOCALITY " 1 + �w ' nnAIA,OLE REFERENCE ZIPPER
permit is for one hundred dollars ($100` or less.) �� t OWER
N FAREST !YPE OF CONNEGT�ON LE.NC HFROM
I certify that in the performance of the work for which this cRos-s S, 1 0�(�li�L4 1i• /I vi r CURB PL Mt T)P
permit is Issued, 'I shall not employ any person in any manner LEGAL PC ,0
so as to become subject to the Workers' Compensation Laws. DESCRIPTION Lo NO CO IMP NC OB NO
Date Applicen!
BLOCK TRACT � D� � 'PUNK PERMIT N: ROAD PERMIT NO
_ _ _
NOTICE TO APPLICANT If after making this Certificate of MAPrB'OK aPFiDAvlr wAIvER FASF.MENT RECORD wSTR_70T
o DATE
Exemption, you Should become subject to the Workers`
Compensation provisions of the Labor code, you must forthwith No.of eI Das.
p p y zE or-LCT;r�"' ;K' '� Now ON t..oT Hwv OPST WIDENING
comply with such provisions or this permit shall be deemed uSEor-
revoked. 3'JIl.OINGS STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION PFRMIT NO_ ,
I hereby affirm that I am licensed under provisions of Chapter
OWNEH ..,i��
9 (commencing with Section 7000) of Division 3 of the Busi- MAIL. r „ - '., � "
Hess and Professions Code,and my license is in full forte and CHARGES
ADDRESS,
effect. -^.. - ' ....i/ CCNNECTtON CHARGE FEE
License
:,7-.'fM'.' ``- �3 ,. > TEL- NO. "%` ,_2,/..- r'?
License Number`_ _bc.Class RE:.MBDRSEMENT FEE
CONTHACTOR
Contractor. _ __DateDSTRICT NO GROLiP MAP PROCESSED BY
ADDRESS SK PG
❑ I am exempt under Sec.— �of the LA. Co, z
Ci?Y TEL NO. - .,. "°'S, .sf'y�. ;.,.-ter,,. 0.
J
Plumbing Code and'or Sec of the TATE uc. P.vAL U
LiCENs=NO. CLASS DATE VALIDATION
B & P. Code for the following reason- NO. DESCRIPTION OF WORK FEE ` O
OUSE SEWR :0NNEC"ING T.? FINAL r% �
Dale y i BUC:.SEWER . ,- {„' 9r
SF IC TANK SEEPAGE PIT OR LU
Signature P S AND OR DRA.NF ELD CLCL
�OjSt.SEWER CONECTING TO
OWNER-BUILDER DECLARATION PR✓ATE DISPfsAL SYSTEM z
I hereby affirm that I am exempt from the Contractor's License CONNECT AD'S TIONAL BLDG :OR q
Law for the following reason j$eetan 7031.5, Bulsness and Pro
NORK T()HOVLSE SEWER ' ^= l'^^` 73.50
fe5siORS Code): 'ry FPPL,VV SEEPAGE PIT DRAiNFTE D q MS
i,rr
rxTN CF SPJICL DR,WEa MANHOLE ,F
property, Y p y g ALTER RLP1 R OR AeIA.NDON Heu.4
I, as owner of the or m employees ee5 with wages as �;; ,p �-y�•�
EWER OR D spOSAI. ,,STEM 1=..} 1;... Tit' - x ^..-��t,...�
their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business .7-1 1.
w: t 44.i
and Professions Code)
,s
EJ I, as owner of the property, am exclusively contra, ' y rE
n.ting with OWNERS Permit $ .-,�� ,�'�"
licensed contractors to construct the project (Sectio7044, _
Business and Professions Code). AUTHORIZATION TOTAL FEE 'i -_ ,
CONSTRUCTION LENDING AGENCY I HAVE At THIS 7ATE A CCNTR4,1,T s 'H .HE HEREIN .,AVEI r TPACTOR Tc' 00001-0031 P28/e6
I hereby affirm that there is a construction lending agency CnNi`FC THE ABOVE DESCRIBED EXIST N---, :rtp iN"To THE P„,.L.�...EWER P a
for the performance of the work for which this permit IS r� �0
Issued (Sec. 3097, Civ. C.}. SIGNFD TH!S__—_�__D r OF 19/
OWN OR
Lender's Name _�_._— ----------- wN R aGEN- - -j —
Lender's Address
1 certify that ! have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing ;and Sewers,
and hereby authorize representatives of this County to enter
Upon the above-mentioned property ;or inspection purposes.
Signature of Permittee -Date SEE REVERSE FOR EXPLANATORY LANGUAGE