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Home My Public Portal About5039 SERENO DR_Sewer__ WORKERS COMPENSATION DECLARATION 1 20-0051 DPW ales 11 I herefty ofbrm that I hove a certificate of consent to self LI Insure or q<Prtiflcole of Workers Compensation Insurance or 76,45 O s r a certified copy Iherea„sec 3800 Lab � , APPLICATION FOR PERMIT ,�,,o.,,``�''�� s.� 4 Policy No ompany S}''VTD ❑ nfied copy Is hereby furnished _ SEWER - SEWAGE DISPOSAL t RCertlbed copy is filed with the county building Inspection COUNTY OF LOS ANGELES .BUILDING AND SAFETY department � �� ^ BUIL tl Date 77/Z l-./.-Applicant IA.An i'i7�t��eki...� I FOR APPLICANT TO FILL IN CONNECTION DATA 7 CERTIFICATE OF EXEMPTION FROM WORKERS auILDtNG COMPENSATION INSURANCE ADOREss 5503 STATION DEPTH This section need not be completed If the workunvolved b the UPPER ( P Y MANHIXE REFERENCE permit Is for one hundred dollars (f 100) or less ) LOWER NEAREST T - TYPE OF CO ON LENGTH FROM I certify that In the performance of the work for which this CROSS ST CURB v CURB PL mE TOPL permit Is Issued I shall not employ any person In any manner LEGAL PC NO , so as to become subject to the Workers Compensation laws DESCRIPTION LOT NO CO IMP No toe No Dole Applicant BLOCK TRACT ' TRUNK PERMIT tip ROADRRMITPFO + NOTICE TO APPLICANT If after makm th is lCerDbcate of ASSESSOR AFFIDAVIT WAIVER EASEMENt RECORD INSTR NO DATE Exemption g MAP BOOK PAGE PARCEL You should become subject to the Workers NO OF BLDGS Compensation provisions of the Labor code you must forthwith SIZE OF LOT NOW ON LOT HWY CRST WIDENING comply with such provisions or this permit shall be deemed USE OF revoked . BUILDINGS STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION y�� PERMIT NO I hereby affirm that I am licensed under provisions o/Chapter OWNER Serew Pacific Lin t..CU PartnerSIU 9 (commenang•wtth Section 7000, of Division 3 of the Busl VMIL Ss 4700 Miller Qr. UTll 5) CHARGES ness and Professions Code and my license Ism full force and effect oo �• GTY TEL NO CONNECTION CHARGE FEE License Number �` ��lri LIc Class ��7 Z— T �, REIMeu RSEWNT FEE (' ./ CONTRACTOR V L� ContractortiEL`C 1L.�as41.J4-+ Dote 7�f / �[-L_ olsrRlCTrq GFtIwP MAP PROCESSED By ADDRESS L 5 U[J O 3 e< w ❑ am exempt under Sec of the L A Co CJ /C- Gltt ��1EL N �f- O Plumbing Coda and/or Sec of the STATE �Q ,NAL U LICENSE NO J �J C SS�� DATE V LIDA N = B d P Code for the following reason "D DESCRIPTION OF WORK FEE +I �ti O HOUSE SEWER CONNECTING i0 `�(fes FINAL F Date PUBLIC SEWER / if BY W ` SEPTIC TAM SEEPAC PIT C4 Signature PRS AND OR DRALNFiFLD N OWNER BUILDER DECLARATION HOUSE SEWER CONNECTING r0 ► Z PRIVATEDISPOSAL SYST m I hereby off lrm that I am exempt from the Contractor s License CONNECT ADDITIONAL BLDG OR - Law for the following reason (Secton 7031 5 Bu,sness and Pro WOR°TO HOUSE SEWER -_``!7 J r fessions Code) OVERFLOW SEEPAGE pn pRAINFIELD ERTN CESSPOOL DRYWELL MANHOU ❑ I as owner of the property or my employees with wages as ALTER REPAIR OR ABAINECN HOUSE 1 :!FI F� SEWER OR DISPJSAL SYSTEM their sole compensotan will do the work and the structure f ff;2L �f 4 eS is not Intended ar offered for Sale (Section 7044 Business + ` and Professions Code) ,s _ '.�UN Eli,,_'_ ❑ I as owner of the property am exclusively contracting with OWNERS Permit S 2.4 licensed contractors to construct the project (Section 7044 Business and Professions Code) • AUTHORIZATION TOTAL FEE 3 S], CONSTRUCTION LENDING AGENCY , HAVE AT THIS DATE A CONT°ACI WITH THE HEREIN NAMED CONTRACTOR TO I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DBCRIBED EXISTING DMLLING to tHE PUBLIC SEwlR ► I1�� I-I_gJl1� L, 5�? for the performance of the work for which this permit is I7 _ �� Issued (Sec 3097 Gv C ) SIGNED iH15 L' AV Of LVL y„ _ YB7 OWNE Lender s Nome OWNERS Rs A AGENT Lender s Address ADDRESS a4.17✓lae� d .t?Tr.A--�� 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 jaws regulating Plumbing and Sewers i and hereby authorize representatives of this County to enter .x upon the above mentioned property for Inspection purposes Ign r of Perm,tt ate SEE REVERSE FOR EXPLANATORY LANGUAGE I