HomeMy Public PortalAbout5526 ROBINHOOD AVE_Sewer__ F WCIRKERS'COMPENSATION DECLARATION
1
, 20-0061 DPW 6189
I.hereby:d'(Flrm that I have a cbrtLficote of consent to self
rniurLti, oro certificate of Workers'Cor�tpensan Insurance, ori
a certified copy thereof (Sec. 3800, Lab C.) APPLICATION FOR PERMIT t
Policy No. -Company
❑ Cartlfled copy is hereby furnished. SEWER - SEWAGE DISPOSAL
❑ Certified copy is filed with. the county building inspeolon COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Date Applicant -' FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMP7LON FROM WORKERS' o r( STAT� �1 �jQ DEPTH
COMPENSATION INSURANCE AbD ('J ' �. D / O
(This sectiorL need not be completed if the work involved by the MAN REFEENCF UPPER
permit is for one hundred dollars ($100)or less.) . LOCALITY L
NEAREST TYPE OF CONNECTION_ LENGTH FROM
I certify that Inthe performance of the work for which this CROW ST. Y atrt6 P L AA L TO P L
permit Is Issued, 1 shall not employ qny person In any mariner LEGAL
so as-to become subject to the Workdrt' Compensation Laws. DEET IONO
_RPTN LOT NO. co VrrP NO P P C C NO
Applicant �"OGx TRACT TRUNK PERMIT•NO ROAD rERW NO
Date
AR
NOTICE SO APPLICANT: If, after making this Certificate of M.P�x qu3E [ PAF p�� " ID"^T wArvER fAsEtirErrt RECORD LHsr' NO DATE
Exemption, you should b*come subject to the Workers' NO OF ELDt38
Compensatlon provisions of the Labor code, you must forthwith SLE OF LOT S S Now ON LOT HWY OR ST WIDENING
Comply with such provisions or this permit shall be deemed LM.)1 % sTATFercRo Enrt
revoked. EiUILDINOS es,d
LICENSED CONTRACTORS QECLARATION �wwT No
I hereby affirm that I am licensed under provisions of Chapter COON ER �(V Y�/n p
9 (commencing with Section 7000) of Division 3 of the Bust- KAJL (�� Ave, CHARGES
ness and Professions Code, and my license is In full force and
effect. C:Fry TFL CON ECTKsv CHARGE FEE
License Number LIc.Class RE Nr r$
CONTRACTOR
Contractor Date DISTRICT NO GROUPP MAP PROCESSED BY
ADDRESS 'A PG
❑ r am exempt under Sec. of the L.A,Co. CITY TEL No D�
Rlumbin9 Code and/or Sec. of the STATE uO. NAL
LKX-NSE No. CLAsa DATE "LIDATION
B. 8 P. Code for the following reason No. DEecatPTR ►r
OOrwORK FEE =O
HOUSE SEWER COWFECUNG TO RtVM I T
Date PUBLK SEWER By ---�.,
K TAMC AGE PIT OR I V E3433 75L
Signature P AfY Cxi DRAINFCD
OWNER-BUILDER DECLAMATION HOUSE R CO MELTING TO 1 ITEMS coZ
PRNA _
I hereby affirm that 1 am exempt from the Contractor's License CONNECT ADDn-O BLDG OR {Cr�,U55 35
Law for the following reason (�ecton 7031.5, BuJsness and Pro- woRKTO,HanESRWER
�JERFIOW SEEPAGE PIT.DRAINFELD
fesslons Code): ExTN CESSPOOL DRYWELL.MANHOLE [ r.6.35
I, as owner of ther0 ALTER REPAIR OR HOUSE
p pe Pty,or my employees with wages as SEWER OR DISPOSAL SYSTEM Ly1AyL-C �I11
their sole compensation, Will do the work and the strycture SLI
is not rntended or offered for sole (Sectlon 70", BusineV.
and Professions Code},
❑ I, as owner of the property, am-exclusively contracting with OWNER$ Permit
licensed contractors to construct the project (Section 7414, 1 �I
Business and Professions Code). AUTHORIZATION TOTAL FEE 36135 AM
35
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WLTH THE HEREIN NAMED CONTRACTOR TO
I hereby affirm That there is a -construction.lending agency CONNECT THE ADOVE DESCRIBED EXISTNIC,DWELLING TO T}-¢PUBL+c SEWER ,
for the performance of the work for which this permit is
issued (Sec. 3097, Civ. C.). SIGNED THIS 24 DAY OF "Lick 19
Lender'f Name O m^EErRS AGENT
Lender's Address ADO14 ZMWI A!#1104 440" 09 �
I certify that I have read this application and state that the
above Information Is correct- I agree to comply with all County
ordinances and State laws regwiating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upon the above-mentioned _rope rty for Inspection purposes.
/ la l
Signature of ee Datei SEE REVERSE FOR EXPLANATORY LANGUAGE