HomeMy Public PortalAbout5041 SERENO DR_Sewer__ WORKERS COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to self 204MI DPW 6" TUI
ensure or a SeNlficote of Workers Compensation Insurance or I6AS420
a,ceNd,ed co (here f (5e<pony
Lab C ) A / APPLICATION FOR PERMIT
Policy No A( ompany � Fes/
❑,/Ce�tlfeed copy ,s hereby furnished SEWER - SEWAGE DISPOSAL
Lam' Cerl,hed copy is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
deportment /� �`T E "
Dote LgppllcontJylE—fes FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM'WORKERS I BDLwr+G
COMPENSATION INSURANCE AODREss STATION DEPT.
(This section need not be completed If the work involved by the UPPER
LOCALITY MANHOLE REFERENCE I R
I permit s for one hundred dollars (of Th or less ) TYPE OF CONNECTION aNcTH FRS
1 permit
i then d the performance of The work for which manner
N2$85T
permit IS issued I shall not employ any person In any manner Y CURB P I CMI To P I
I so as to become subject to the Workers Compensation Laws LEGAL - PC NO
�1 t DESCRIPTION LOT NO CO N•n NO ICG NO
Dole Appleconl BLOCK TFUCT TPUNS PERM1NI NO ROAD PERMIT NO
NOTICE TO APPLICANT If after makingthis Certificate of ASSESSOR AFIIDAVIr WAIVER EASEMFNr RECORD IN51R NO DATE
MAP BOOK PAGE PARCEL
Exemption you should become subject Po the Workers NO OF SLOGS
Compensation provisions of the Labor code you must forthwith SZE OF LOT NOW ON LOT
HIWY 0451 WIDENING
I comply with such provisions or this permit shall be deemed USE OF
revoked BUILDINGS STATE ENCROACHMLNI
LICENSED CONTRACTORS DECLARATION PERMIT NO
I herebyaffirm that I am licensed under OWNER
Amon 3 f Chapter
9 (commenting ions Section d mr, of Divilicense
is i 3 0l the Bun ADDREss CHARGES
ness and professions Code and mY license u m full force andgxxxr,
effect �y r w 0" TEL NO CONNECTION CHARGE FEE
I I- �'�`�� S(�•'�✓�LIC CIOSS��Z REIMBURSEMENT FEE
I Llceroe Number
E-S.�/GA�+c7'� Date 7� JC7 Z- CONTRACTOn (-•icy 7Z'n..�
Contractor_ DISTRICT nID GROUP ,.uP ESRD Br
/ ADDRESS BX PG
❑ I am exempt under Sec of the l A Co 7� 7 Z_
STACITTEL NO O
Plumbing Code and/or Sec a(the UCEN LTC TATE O
1 (CENSE NO cuss DA[ LLIDATION =
B 8 P Code Torr the following reason No DEscRrorloN OF WORtE FEE 11_ `}/ 0
' HOUSE SEWER CONNECTING TO FINAL U
Date PUBLIC SEWER BY
SEPIK TANS MERAGE AT OR
Signature PITS AND OR DRAINFIELD
HOUSE SEWER CONNECTING 10
OWNER BUILDER DECLARATION P4rvnrE DI L,1 TTM
TED
I hereby affirm that I am exempt from the Contractor s License CONNECT ADDITIONAL MDG OR
Law for the following reason (Secton 7031 5 Buisness and Pro Vi`ORa TO HWM MwER
lessons Code) CNERFLOW SEEPAGE PIT DRAINF'ELD ,
EPiN CESSPOOL DRYWELL ALANHOLE
❑ I as owner of the property Or my employees with wages as ALTER REPAIR OR ABANDON HOUSE
1�
I their sole compensation
OR DSIV'S/ SYSTEM
will do the work and the structure 1 -
Is not Intended or offered for sole (Section 7044 Business
and Professions Code) - (��Gj.t
El as owner of the property am exclusively contracting with OWNERS PBErT'l 11 S 1 1 S CLIJ] it._Id
licensed contractors to construct she prolecl (Section 7044
Business and Professions Code) AUTHORIZATION I TOTAL FEE 3 ^I1 ITEM':,
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO )fry}AL 66 - 53
1 hereby Affirm that there Is o construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING CNEUING TO THE PUMIC SIMP
for the performance of the work for which this permit IsPilo
- f hE�� �jrc_
Issued (Sec 3097 Civ C ) SIGNED THIS DAY OF I9
Lenders Name OWNER OR / fHAP ,Lila
OwNERE 5 AG.ENNTT
Lender s Address ADOREss /{j 72r' �' ZA*d.
[iOGrl-n Kt1 q� 5/
I certify that 1 have rood this application and state that the � T.
above Information Is correct I agree to comply with all County - ¢$Il{ 1 2:24ordmonces and Stale'Iaws regulating Plumbing and Sewers
and hereby authorize representatives of this County 10 enter
upon the above mentioned property for Inspection purposes
Igna ermllle Dot SEE REVERSE FOR EXPLANATORY LANGUAGE `