HomeMy Public PortalAbout5038 SERENO DR_Sewer__ NiOIIILERS COMPENSATION DECLARATION
1-hereby yffirm that I have o certificate of consent to self
insure, w a certificate of Workers'Com enation Insurance,or rA4F20
a` Sac 3800• �°°ce°°""" APPLICATION FOR' PERMIT
1 p y o Company
t i5d
y furnl.hed _ SEWER - SEWAGE DISPOSAL
with the co n b I Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
Domnt FOR APPLICA TO FILL IN - CONNECTION DATA
XEMPT N FROM RS SATION INSURANCE AADDDRRESS STATION DEPTHI
(This seciion need not be completed if the work involved by theLouLav spa�RQ� _ UFFER
permit is for one hundred dollop(5100)w leu) CONNECTION LENGTH NEON
I certify that in the performance of the work for,which this - NE�q ST - - - TYPE OF
9 CURB P L M I TO P L
permit Is Issued, I shall not employ any person In any manner 'P O NO
so a11 to become subject to the Workers'Compensation laws OWNER oD " NO .000140
•
3 AV'K `S TRUNK 14RAVT NO ROAD PERAVT NO
Date Applicant ADDRESS
AFFIDAVIT WAIVER EASEMENT RECORD �NSTR NO DATE
NOTICE TO�APPLICAM If, cher making this Certificate of CITY by NEI
Exemption, you should become sublect to the Worke
Compensation provision of the Labor code,you must forthwith Dcs[aivrHON LOT No
comply with such provision or this permit shall be deemed HWr OR ST x�tblNG
revoked A, at= TRACT STATE ENCBOACHMEM
FID OF BLDG$ PERIWT NO
LICENSED am licensed
under provisions
SIZE OF LOT caw ON LOT
1 (commencing
i that I Se licensed under provision f Chapter USE OF
9 nandPrwith Section d my of licDiviense
is i 3 of the Bust- BUILDINGS CHARGES
nen and Profeul s C and my license Is In full fwcrd i 004,"CTION CHARGE F o
L en C, L'Ri Y1 NT FEE
r w to / DISTRICT No GROUP AMP PROCESSED eY
p
❑ SK PG
1 am exempt undo� c o/the L A Co I A�A7�
Plumbing Code and/w Sec of the NO I DESCRIPTION OF WORK FEE Nrrk VALIDATION N
PUBLIC
WR CONNECTING TO DATE /✓ '/�/J/
B 6 P Code for the following reason S11"M TANK SEEPAGE mao crv� LL TT Z"
Date NTS ANDrOR CRAINNEID eiau
nous SHYER CONNECTING TO
MFVAT1
Signature CONNECT ADDrnONAL BLDG OR ,
OWNER-BUILDER DECLARATION Wax TO HOUSE SEWEE
I hereby affirm that I am exempt from the Contractor s License ExrN DRYWHL MANHOLE
Law for the following reason (Secton 7031 S, Buisneu and Pro- , ALTER REPAIR OR ABANDON HHOUM
fession Code) Da ,
El as owner of the property,or my employees with wages as
their sole compeLaation, will do the work and the structure - - 3,07 17.0j t,
is not Intended or offered for sale (Section 7044, Business Permit f �O 1 ITEM'
and Professions Code) OWNER'S E,
❑ I as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE TOTAL 27 . 00
licensed contractor to construct the project (Section 7044 I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO L
Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER CASH 27.00
CONSTRUCTION LENDING AGENCY I '
I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_ ► 1.} U� .V�
for theOWNER OR '
performance of the work for which this permit a OWNERS AGSM ,
Issued (Sec 3097 Civ C ) -
Lender's Nome ADDRESS ODDO-0001 6/17/?l
Lender s Address _ 7533 1 AM10:54
I certify that I have read this application and state that the
abov ormo Is correct I agree to comply with all County
or cis Sate laws regulating %u bine and Sewer
hnit0y outhwae representatives of a Co ty to enter
po a above mentio rty f Io1193 l ,i
Puryo
Signature ermlttee to UK REVQSf FOR EXPLANATORY LANGUAGE