HomeMy Public PortalAbout4949 RYLAND AVE_Sewer__ ' t WORKERS' COMPENSATION DcCLARATION
1 hereby offirrr? that I have a certificate of consent to self , 26.6,42 DPW 6J8R
msu%e, of a certificate of Workers'Compensation Insurcnce, or :,t
76rfi»2D
° cert, ,el copy thereof (seg 3800 Lab� ' APPLICATION FOR PERMIT
Poor,, h+�------ __.Company ---- -- -- - --
❑ Cerified'cupy is hereby fu,ni5hed SEWER - SEWAGE DISPOSAL
r] Certified copy is filed with +he county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
deportn,,ent
Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING D
r
COMPENSATION !NSURANCF ADDRESS ! .(,; STA r EVTH
iThls section need not be completed If the work involved by the � Mwr,r,;,iE RP rR£NCF UPPER
LGGAL9TY ,�'`, _ LOWER
permit is for one hundred dollars ($1(70) or less ) TYPE OF CONNECTION NEAREST LENGTH FROM
1 certify that In the performance of the work for which this SS OT. r CURB M 1 To P L
permit is issued, I shall not employ any person in any manner LEGAL _ 'P r Pdfl
so as to become subject io the Workers'Compensation Lows. DE CRIPTION LOT NO, Co Mp NO jcB No
BLOCK TPAQT TR,:NK PERMIT NO ROAD PERAArT NO
Dole--Applicant -
NOTICE TO APPLICANT: If, after nakin this Certificate of MAP ASSESSOR
AFFIDAVIT WAVER EASEME RECORD INSiR NO DATE
C] dAAP 60CK I PAGE PAFCEL
Exemption, you should become subject to the Workers' NO OF BLDGS
Compensation provisions of the Labor code, you must forthwith SIZE OF LGr NOW ON LOT HWY OR ST WIDENING
comply with such provisions or this perini! shall be deemed USE OF -
revoked. BUILDINGS STATE EN(.PiDACHh1ENT
Pf.RMIT NO
LICENSED CONTRACTORS DECLARATION —
I hereby affirm that I am licensed under provisions of Chapter oW14ER
9 (commencing with Section 7000) of Division 3 of the Bus; MAIL
ADDRESS L L �� HAG�ES
ness and Professions Code, and rn)!License is in full force and
effect qq .-
n-}� �'�V'- k"!`-*L Ci..NC}. ��- C.�NNELT`ION CHARVE FEE
license Number _Lic.Class—_^ M RE.ABURSEMENT FEE
CONFRACT-UR 'S 'o +- "
Contractor— Date DISrRtCTNC> .ROUP MAP vRQCESSEO,Bv _
ADDRESS Bk Pry •.� ,�' .-.
I orn exempt under Sec. of the L A Co.
!>iTy TEL NO. f J;L`G V ! 0
Plumbing Code and%or Sec. of the STATE LIC. ',A' 0
4A-I0AT10N
L,CENSFNo CLASS DA'F<. r ) z
B. & P. Code for the following reason NO. DESCRIPTION OF WORK FEE { a ��'9 -3 !3
7
HC U i SEWER O. NEE.NC;TQ F NA_I 1 ",
Dote PUBLIC fNER
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-�_--- FP7I( TANK SEEPAGE
M OR - ate - - 1 ,1 3 E"j i; W
Signature—- 4 PITS AND OR DRA.,NFIELD
HOUSE SFwER ONNECTING TO �
OWNER-BUILDER DECLARATION f R VATF DISPc AL SYSTEM. � MAIL " ° 7 ' A
I hereby affirm that I am exempt from: the Contractor's License ONNE_-ADD n(DNAr BLDG OR tr}� j
Law for the following reason (Sector.7031.5, Buisness and Pro VV-IRK TO HOvSF SE:+, R CASH `y9. y
JV ERF.Ow SEE AGE PIT DRA,NFIFLD
fes5ions Code): p Z
E%TN.CES P SOL. 'DRY W'Fit MANHOLE �,���'��
A TER REPAIR JR ABANDON HOUSE r.�.s.l
CJ I, as owner of the property, or my employees with wages as
SEWER OR SN'',A,SYSTEM
their sole compensation, will do the work and the structure ---- —
is not intended or offered for Fa!e (Section 7044, Business t, r,Fgy11'J/96/0
;� ++
and Professions Code00. ----- -- 0 [000 "
as owner Of the pro ert am exclusive) Contracting with r
p v g OWNER'S Permit $ 63`91 1 AM 1.5--4
icer+sed car.tractars +o construct the project (Section 7G=t4,
Business and Professions Code). AUTHORIZATION TOTAL FEE
CONSTRUCTION LENDING AGENCY` HA.oE At ITIS H A _iO TRACT W TH T.F "FQEiIr NAMED
! hereby affirm that t}sere is a canstructian lending agency NNECT tHE ABOIE VS1INC IM-LiNr,TO T'IE PUP, se ER
for the performance of the work for which this permit Is
issued (Sec. 3097, Civ C J, stCNi THIS___,___DAY
OWNfR GR
Lender's Name--- ---'-- -------- --
lender's --
I certify that I hove 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,
ao8. .hiprebv a�LrthQrize representatives of this County io enter�pon 4e above-mentic3ned property for inspectionit 4
plrpoSeS.
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noture 0f erm,ttee Dote SEE REVERSE FOR EXPLANATORY LANGUAGE