HomeMy Public PortalAbout5564 ROBINHOOD AVE_Sewer__ "KN5'COMPENSATION DECLARATION
I hereby affirm that I have a certtficate of consent to self
AInJure, or a certlflcate of Workers Compensation Insurance, or
a certified copy thereof (Sec. 3W0, Lab C:) a Ka(WV. APPLICATION FOR PERMIT
Policy No. Company i es
ertifled copy Is hereby furnished. SEWER - SEWAGE DISPOSAL
�C
❑ Cerilfled copy Is filed with the county b on l COUNTY OF LOS ANGELES BUILDING AND SAFETY
d rtmani.
CIEDate III FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATF OF FROM WORKERS' eusgNo F sTATtbN DOTH
COMPE(,iSAT10N I URANCE ADDRESS
(This section need not be completed if the work Involved by theLir Aw�s-puERE�ra nam
permit Is for one hundred dollars (;100)w less.) TYPE OF LENGTHNEAREST N FROM
I certify that in the performance of the work for which the CRM ST. Y. CURD P.L ALL TO PJ—
permit
lpermit Is Issued, I shall not employ any person In any manner Pc NO
so as to become subject to the Workers'Compensation Laws. �tt,� Co. Boa No. O
- V
MAIL TRUNK P6tAVT ROAD PHUVT-NO.
Date Applicant ADS
NOTICE"Tb APPLICANT: If, after mdking this Certificate of Ta-No. APRDAvrr w REooRD.INSTR.NO. DATE
Exemption, you should become subject to the Workers LEGA6
Compensation provlslons of the Labor code, you must forthwith DESCRirrroN LOT NO. aryyf.ORST.wDENING
comply with such provisions or this permit shall be deemed
revoked. TRAcr STATE Z
NO.OF N Dos. PERMIT NO.
LICENSED CONTRACTORS DKQARATTON sag OF LOT NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter USE of
9 (commencing with SecTlon 7000) of Division 9 of the Busk 6uILDINGS L aaAROEi
nese and Pof*sslons Code, and my license Is In full force and
RGE FEE
effect. CONTRACTOR '�o-a'''
License Number3 LIc.Class r I �D _ Em
ConncxCI Date 1 0--�}I L/ Crr, TEJ-"a �a oraTR)CT NO. GROUP MAP PROC6S»BY
SK MAP
- ElI am axWnpt under Sec. of The LA.Co. � �L�rg a
�LI. �.Ass
Plumbing Code and/or Sec. of the No DEsc:RI TO p,jE VALIDATIOrI
B. & P. Code foF the following reason PU°UC
SEWER
T SEEPAGE PTT OR RNAL
PRS M,A DRAiNRELD By .
Date HOuSE sewER coNmEcTINGTo .
Signature CONNECT AMTTroNAL UPa.OR
OWNER-ElUILDER DECLARATION WORK TO HOUSE
OVERFL1 hereby affirm that I-am exempt from the Contractor's License ExTN. owe DRQ1410=LE Y
Law for the following reason (Secton 7031.5, Bultness and Pro- A1TSL REPAIR ASA�N HCkM
fesslonS
s Code): 5�OR.
❑ I,as owner of the property,or my employees with wages as :2 70 6 5 A
their sole compensation, will do the work and The structure #To o''o•
Is not Intended or offered for sale (Section 7044, Buslness o0
and Professions Code). OWNER'S Permit $ 2 0 0 7,50
❑ I,as Owner of the property,am exclusively contractfng with AUTHORIZATION TOTAL FEE
licensed controctors to cgnstruct the project (Section 7044, T TFUS DATE A CONTRACT wmH mf hE38N NAMED TO .0 o ° 1 7. 505
Business and Professlons Coded cor}tc7 THE AbO%T Dtb m oasnNG owEL.LwG To THE Pueurc SPAU 1 j '`
CONSTRUCTION LENDING AGENCY Q 2 S'2
I hereby affirm that There Is a construction lending agency �'��� DAY C)F v`' 19
OOR
for the performance of the- work for which this permit Is Y4�1EO�Z
Issued(Sec. 3097, Clv� C.h ADORFsb
Lenders Name
Lender's Address
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 regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upon the above-me operty for Inspection purposes.
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SI Date sm Rrvwm I'OR DtTlm ATOkY LANGUAGE