HomeMy Public PortalAbout5045 SERENO DR_Sewer__ WORKERS COMPENSATION DECLARATION
I hereby affirm that I hove a certificate of consent to self 700031 DPW SM
Insure or oterld¢ate of Workers Compensation Insurance or 76A847D
Po cy O cop thereof Sam � � APPLICATION FOR PERMIT
Q Certlf kopy is hereby furnished SEWER - SEWAGE DISPOSAL _
ertdled copy Is filed with the county building Inspection COUNTY OF LOS ANGELES .BUILDING AND,SAF1ETY
deportment n
75
Date Appllcont �tl��iL/-dc�--- - FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS i BUILDING
COMPENSATION INSURANCE AGGRESS STATION DEPTH _
(This section need not be completed If the work Involved by the MkNIHCXE REFERENCE UPPER
permit is for one hundred dollars ($100)or less ) LOCALITYa.
I certify that in the performance of the work for which this NEAREST - TYPE OF CONURB FAIL LENGTH
crwss ST FlICl[Lltd Avenue r cute P t FAIL TOPt
t
permit is Issued 1 shall not employ any person In any manner LEGAL
Pc NO
so as to become subject to the Workers Compensation Laws DEscwPTloN LOT NO Co IMP No Eoe NO
BN
LOCK TRACT TRUK PERMIT NO ROAD PERMIT NO
Dale Applicant
NOTICE TO APPLICANT If after making this Certificate of ASSESSOR ' AFF IDAVO WAIVER EAEMLFRT RECORD INSTR NO DATE
9 MAP BOOK PAGE PARCEL
Exemption you should become subject to the Workers NO OF BLOOS
Compensation provisions of the Labor code you must forthwith SIZE OF LOT NOW ON LOT T
comply with such provisions or this permit shall be deemed USE OF Hwr OR St WIDENING
revoked I BUILDINGS STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION PERMIT NO,
I hereby affirm that I am I¢ensediunder provisions of Chapter OWNER Sereno Pacific
9 (commencing with Section 7000) of Division 3 of the Busl MAIL 4700 Miller OT' CHARGES
ness and Professions Cade and my license Is In full force and ADDRESS
effect Gtt TEL NO CONMCTICN CHARGE FEE
License Number SZg S' Lic Class REWBURSEMENT FEE
2 CONTRACTOR
Contractor JIL le DISTRICT nE0 GROUP MAP PROCESSED By
ADDRESS /¢ u [� SK PG
❑ I am exempt under Sec of the L A Co cin, TEL NO L1,111
—Z ( �•v b "5
Plumbing Code and/or Sec of the STATE u FINAL
LICENSE NO CLASS � DATE r� V LIDATION =
0 8 P Code for the following reason ND DESCRIPaOM OF WORK FEE E,� 0
F` HOUSE SEWER CONNECTING t0 1 NAI F
Date PUBLIC SEWER eY 0
W
SEPTIC TALAR SEEPAGE LPITD Do 4
Slgnoturo GRAINFIELD
AND OP pRAto
FgUSE SEWER CCNF�ECTING TO
OWNER BUILDER DECLARATION t PRN4Tf L SYSTEM -
I hereby affirm that I am exempt from the Contractors License CONNECT ADptIDNAL BLDG OR
Low for the following reason (Secton 7031 5 Bulsness and Pro svoRK TO HOUSE SEWER -
fessions Code) CWRFLOW SEEPAGE PIT DRAINFIELD
1 EKTN CESSPOOL ORYWEIL MANHOLE
❑ I as owner of the property or my employees with wages as ALTER REPAIR Ort ABANOON Ha Li r1 ^
1G
then sole compensation will do the work and the Structure
Sf WER OR DISPOSAL SYSTEM
is not intended or offered for sale (Section 7014 Business (i(("r•a
and Professions Code)
❑ I as owner of the property am exclusively contracting with �'G7 C3• L
licensed contractors to construct the project (Section 7044 - OWNER'S Permit _ fJ2_ -
Business and Professions Code) AUTHORIZATION TOTAL FEE
CONSTRUCTION LENDING AGENCY HAVE AT THIS DATE A CONTRACT WITH iF( HEREIN NAMED CONTRACTCq TO , TQ fri,,{{
L (} -,
I hereby affirm that there Is a construction lending agency CONNECT THE ASOW DESCRIBED EXISTING DNFLLING TO THE PUBLIC SEWER _
for the performance of the work for which this permit Is T i CHECK - 6'_.::
Issued (Sec 3D97 CIv C ) SIGNED/His DAY OF /inti 19�
tTVNER oo T— CHANCE MLI
Lender s Name OWNERS AGE
,
Lender s Address ADDRESS
I certify that I have read this application and stale that the QI�h11 I—),p-f�1 _f /'/21
above information Is correct I agree to comply with oil Countyi s .l
ordinances and Stole laws regulating Plumbing and Sewers .I
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and hereby authorize representatives of this County to enter ,
upon the above mentioned property for inspection purposes
Sign re of Per t to SEE REVERSE FOR EXPLANATORY LANGUAGE