HomeMy Public PortalAbout6163 RENO AVE_Sewer__ WORKERS' COMPENSATION DECLARATION 20-0051 DPVV 6189
I hereby affirm that I have w certificate of consent 10 self 716AS42D
rx re, or a certificate of Workers' Compensation Insurance, OF
f,dlb�-c OT"Y ;h e r 8 0 f S 3800, Lab C.I
APPLICATION FOR PERMIT
Policy Noany
Certified copy is hereby furnish". SEWER - SEWAGE DISPOSAL
Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department
Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDINGSTATICiN DEPTH
COMPENSATION INSURANCE A 1,J C) ;41,iir
(This section reed not be completed if the work involved by the, MANHOLE RIFFERNCE
permit is for one hundred dollars ($100)cri less,) LOCALITY PLE (''i . ��'/ *le" LOWER
li,1
NEAIIEErT TYPE OF CrI GN LENGTH FQOO
I certify that in the 'performance of the work for which this .r.4"It i 17 br, n-uc Y M� TO PL
permit is issued, I shall not employ any person in any manner
LEGAL IT Not
so as to become subject to the Workers' Cory)pensatiori, Laws.. _DESCRtPII0N LOT NO c:,O VP NO JOB NO
Date Applicant Bi,QCK_jt: TRACr 'P1,NK PERM T NO ROAD PERMIT NC
ASSESSOR PAGE PARCE L AFi`IDA,tT I WAIVER EASEMENT RECOPD.INSYR NO DATE
NOTICE 10 APPLICANT! If, after making this Certificate of MAP 1�80K
Exemption.
on. you should become Subject to the Workers NO OF BLr`GS
Compensation provisions of the Labor code, you must forthwith SIZE CF ILOT NCv11r ON t D'r FSFVY OR ST WiDEN,NG
comply with such provisions or this Permit shall be deemed USE
revokedSUILDIN-S aSTATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION PERMIT NO
1 hereby affirm that I am licensed under provisions of Chapter OLVNER
9 (commencing with Section 7000) of Division 3 of the Bus; MAIL
ness and Professions Code and m;license is in full force and ADIDIRESS
effect CITY4, 7 _,'NNICTION,-I-4ARGE FEE 4 1 EL,N C1 ;jt 3
3 License Number Lic.Ciass RE4MBURSEMENT FEE
CCINTRA�'_'IIDR PROCESSED BY
41-e MAP
Contractor K, L Date. I i ADDRESS PG PRO,
E I on,exempt Linder Sec.
—of the L.A Co, CL
CITY AIe
0
Plumbing Code and,'or Sec of the STAT NAL L)
LICENSE NCJ' ,Q ATE
f-7 z
�J_ VALIDATION
X�
B. & P. Code for the following reason---- NODESCRIPTION OF WORK FEE / � 1U 0
HOUS)f SEWFRCONNE.TINI�,TQ FINAL
PUBtic SEWER E" /e T.A
5FPriC DANK SEFPAGE Psi OR
PITS AND OR DRAINFIEiD
i-tOUSE SEWER CONNECT:NG TO 3311,13 z
OWNER-BUILDER DECLARATION PRIVATE DISPOSAL S%-ITE.IA
I hereby affirm that I am exempt from the Contractor's License C0NNFZT Ar OVAL BLDG Or a t
Law for the following reason (Sector,7031.5, Buisness and Pro WOIRK 71)HG SF SEWER
fiessions Code): 0vEQ1LC`VV SEEPAGE PIT DRAINFIELD -7 4 7
EXfN CF,SPOOL DRYWEILL MANHOLf
ASTER REPAIR OR ABANDON HOUSE
L-1 I. cis owner of the property, or my employees with wages as CHECK A� ;G
SOVE,R OR DISPOSAL SYSTEM
their sole compensation, will do the work and the structure
intended or offered for sole. (Section 7044, Business
snot
and Profession-) Code).
1, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Section 7044, OWNER'S Permit $ it 96
Business and Professions Code). AUTHORIZATION TOTAL FEE
CONSTRUCTION LENDING AGENCY HA1,F AT Sri,, ,ATE A _ONTWA(:T ✓V.T THE HEREiN 'SAME RAc'OR To f AM"i
I hereby affirm that there is o construction lending agency CONN iCT rI1F A.?�'Vf
I,,,N6 T THE FL.B.. 4tp
for !he performance of the work for which this permit
issued (Sec. 3097, Civ. C SIGNFD THIS LAY OF 19
Lender's Name DINNERS AGENT
Lender's Address Z-491- 17 :kf-0 It-4 ADDRE5S
I certify that I have read this f:)pP hCo;iO and state that ti-i,
above Information is correct I agree to comply with all County
ordinance, and State laws regulcitina Plumbing and 5ewer5,
and hereby authorize representatives of this Coun?y to enter
upon the �Bove-mentioned property far inspection Purposes.
SignatilIre of Permittee SEE REVERSE FOR EXPLANATORY LANGUAGE