HomeMy Public PortalAbout5948 RENO AVE_Sewer__ ' 'WORKERS' COMPENSATION DECLARATION
I'herz*y ffirm that I have a Certificate of consent to self 20-0057 DP4V6lfl3
nstice; or a.=•,rtlficate of Workers' Compensation Insurance, Oro'c7 As42D
Pglcy�fNo. c3510555af (Sep T,y_ -b l- ;')IlT' 1Ty APPLICATION FOR PERMIT
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❑,.eertffied copy is hereby furnished. SEWER - SEWAGE DISPOSAL
Certified copy is filed with the cq my building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department
Date
------._.6/-2[f/-96pplicarJ_ FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING TI,T,0N DEPTH
COMPENSATION INSURANCE ADDRESS
UPPER
(This it Is
need not re completed i00) work involved by the Z'�vl'E7LE CITY, CA MANHOLE REFERENCE LOWER
LOGALIT'r
permit is for one hundred dollars ($100)or Jess.) TYPE OF CONNECTION
NEAREST LENGTH FROM
I certify that in the performance of the Work for which this r_.Rass ST r carte PI, M L To P L
permit is issued, I shall not employ any person in any manner LEGAL
P I NO
so as to became subject to the Workers' Compensation Laws. DESCRIPTION LOT NO CO IMP NO 109 NO
Dare Applicant
BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
NOTICE TO APPLICANT: If, after making his Certificate Of ASSESSOR AFFiDAVII WAIVER EASEMENT RECORD INSTR NO DATE
MAP BOOK PAGE PARGEi.
Exemption, you should become subject to the Workers' No.of BLDGS
Compensation provisions of the Labor code, you must forthwith SIZE OF LOT - NOW ON LOT - HN:r OR ST WIDENING
comply with such provisions or this permit shall be deemed USE OF
revoked. BUILDINGS STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION PERMIT NO
I hereby affirm that I am licensed under provisions of Chapter OWNER NIK NIKOUI
9 (commencing with Section 7000'1 of Division 3 of the Busi MAIL.
DDRESS P.O.pBOX 80788 CHARGES
ness and Professions Cotte, and my license is in full force and
effect. 397884 CITY SAN MARINO, CA 91118NCPGR (818850-3262 CONNECTION CHARGE FEE
License Number _ Lic. Class_ C.,PI /16 REIMBURSEMENT FEE
p• MARRM' & SONS INC• :, 3AGToH A1ARRONE & SONS, INC.
COntr4Cidr Date 12/31/96 (7!STRiCT NO GROUP MAP PROCESSED BY
ADDRESS 9860 LOWER AZUSA RD BK Pc,
I am exempt under Sec. of the 1.A:Co. CITY EL MMU, CA 91731 TEL NO 818/444-2548 L`.r L" r � r-�.>. ''
Plumbing Code and/or Sec. - Of the STATE LIC
F,�,AI U
LICENSE No. 7 GLASS C 36 C 16 ,4T• `_7 VALIDATION
B. & P. Code for the following reason NO. DESCRIPTION OF WORK FEE _174a
o
. HOUSE S"tWER CONNECTIrJG TO J/ y� •AL U
Date PvBLIC SEWER ,rf %'V
SEPTIC TANK SEEPAGE PIT OR - LU
Signature TS AND ,R uRAINF.E D
a
OWNER-BUILDER DECLARATION OUSE SEWER CONNECTING TO
PPNATE DISPOSAL SYS EM ► �� z
I hereby affirm that I am exempt from the Contractor's License CONNECT ADD-ZONAL BLDG OR _ 3303
Law for the following reason jSecton 7031.5, Buisness and Pro- NORK TO HOSE SEWER - -
OVERFLOW WAGf PI'T.DRAINFIEfD E (?
fe55lOn5 Code): EXTN CESSPOOL DRYWELL MANHOJ.E
LJ I,as owner Of the property, Or my employees with wages as ALTER REPAIR i)R ABANDON HOUSE T%SEWER OR DISPOSAL SYSTEM I ...1�Wx:s
their sale compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business ?Q. 4
and Professions Code). t
NC
[� 1. as owner of the property„am exclusively contracting with
licensed contractors to construct the project (Section 7044, OWNER'S Permit $
Business and Professions Code). AUTHORIZATION TOTAL FEE EEtJ"- j€" j t? jffr r
CONSTRUCTION LENDING AGENCY i HAVE AT THIS DATE A Cor4TRACT WITH THE HEREIN NAMED
�014NECT THE ABOVE DESCR BED EXISTING DWE ZING TO THE PUB��C _E a'v""`�
I hereby affirm that there Is o construction lending agency , �,j'+f ..
for the performance of rhe work for which this permit Is v VA—
SIGNED
/� E"r+.l
sued (Sec. 3097, Civ. C). SIGNED THIS { � DAY Yf,- 4=+
OWNER OR
O
Lender's Name WNFRS GENT ✓L �
Lender's Address ALVRESS = r,z !
I certify that I 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,
and hereby authorize representatives of this County to enter
upon the abo e-mentioned property for inspection purposes.
Signature o�otee Date SEE REVERSE FOR EXPLANATORY LANGUAGE