HomeMy Public PortalAbout5043 SERENO DR_Sewer__ WORKERS COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self 2D 0051 DPW BIBLE
Infuse of a te,Lbcate bf Workers Compensation Insurance or 76ASI2D '
Policyihed to the. ,Set ny' Lyb� - - APPLICATION FOR PERMIT
Policy No campaayr a SEWER - SEWAGE DISPOSAL
❑ Cert, ed Copy IS hereby furnished r `
er ified copy is filed with the county budding inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY ,
department ` � L
Dare2./�Applicant Ii�`n TLS-�-. FOR APPLICANT TO FILL IN CONNECTION DATA
�� CERTIFICATE OF EXEMPTION FROM WORKERS ewLOTHG
COMPENSATION INSURANCE ADDREes 51^lip'' DEPTH
(This section need not be completed if The work Involved by the LacAUTY MANN E REFERENCE - UPPER
permit is for one hundred dollars ($100)or less )
- -
I certify that m NEAREST TYPE p COv+ECHON LENGTH FROM the performance of the work for which this C10EISST y CURB PL ALL TOPL
permit is Issued 1 shall not employ any person In any manner LEGAL • P C NO
so as to become subject to the Workers Compensation Laws DESCRIPTION LOT NO CO IMP nIO P C NO
BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
Dole-Applicant
NOTICE TO APPLICANT If after makingthis Certificate of ASSESSOR MFIDAVin WAMR EASEMENT RECORD MPR NO DATE
MAP BOCK - PAGE PARCEL
Exemption . you should become r code
o the Workers NO OF BLDGR
Compensation provisions Of The Labor code you must forthwith WE OF LOT Now ON LOT
comply with such provisions or this permit shall be deemed USEOF Hwr COST vnDEwNG
revoked NHLDINGS STATE ENCROACHMENT
PERMIT NO
i LICENSED CONTRACTORS DECLARATION OWNER Sereno -Pacific I hereby affirm that I am licensed under provisions of Chapter
9,(commencing with Section 7000) of Division 3 of the Busi MAIL CHARGES
Aomew 4
nese and Professions Code and my license is in full force and
effect O Gm le Cit TEL No 818-3S0-122 CONNECTION CHARGE FEE
Ocense Number CLS S:EB Lic Class C` REIMBURSEMENT FEE
/' CONTRACTOR
COniraClW Z3LVJ Baler/� DIf1RCT NO GRWP MAP WESSEDBY
ADDRESS Lzcr O eX x
❑ I oat exempt under Sec of the L A Co a
CITY ' TEL N
Plumbing Code and/or Sec of the STATELJC , FINAL
OASCENSENO CLS —LIZ, DATE VALIDATION
B 8 P Code for the following reason No DEBCRIPTIDN OF WORK FEE �� Q
HOUSE SEWER CONNECTING r0 FINAL
Date PUNTO SEWER BY V
SEPTI TANK EPAGE NT OR LN
Signature PITS AND OR DRAINFIELD a
OWNER BUILDER DECLARATION HOUSE SEWER CONNECTING TO , 110Z
PRIVATE DIS SY i M
I hereby affirm that I am exempt from the Controctor s license CONNFCT ADDITICNAt BLDG aD
Low for the following reason (Secton 7031 5 Bu,sness and Pro WORX TO NOUN SEWER
fessions Code) CNTRTLOw SEEPAGE PIT DRAINFIELO
EXTN CESSPOOL DRYWELL MANN E
❑ I as owner of the property or my employees with wages as ALTER REPAIR OR ABANDGN HOUsr [i
their sole compensation will do the work and the structure SEWER OR DISPOSAE SYSTEM
Is nal (mended ar offered for sale (Section 7046 Business
and Professions Code) I ITEM`.
❑ I as owner of the property am exclusively contracting with OWNER'S PBFTIf $ -241-7!5 I_I��Iji Fj a 513Ilcensed contractors to construct the protect (Section 7014
Business and Professions Code) AUTHORIZATION TOTAL FEE j f;IECK c<.5_
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
I hereby affirm that There Is o construction lending agency CONNECT THE ABOVE DESCRTND EXISTING DWELLING r0 THE PUBLIC SEWER , CHANGE ,oil}
for the performance of the work for which This permit Is �i
issued (Sec 3D97 Civ C ) SIGNED THIS DAY OF
[TVNFR p4 I
Lender s Name pwNERS AGENT g�Iq!I—;IfjJ1 v 5J71
Lender s Address ADDRESS 4si11 1 AN ":1d
1 certify that I have read this application and stale that the
above Information is correct I agree to comply with all County - -
ordinances and Slate laws regulating Plumbing and Sewers
and hereby authorize representatives of this County to enter -
upon the above mentioned property for Inspection purposes
�-Signal a of Permittee Date EEE REVERSE FOR EXPLANATORY LANGUAGE