HomeMy Public PortalAbout5078 SERENO DR_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
msurl, w o csrlrfrwts of Wwkan ComjxrHaotwn Insurance, a• 'sA°'PD - j
APPLICATION FOR PERMIT
Po11ry No Company.
LAS CMifisd copy,n hereby furmshad ' SEWER - SEWAGE WOOSAL.-
❑ Certified copy is filed with rhe county building inspection COUNTY OF LOS ANGELES t BUILDING AND SAFETY
, depor meg)I I '
Date Applicant ji!�ewd" FOR APPLICANT TO FILL IN - CONNECTION DATA
'CER16FICATE OF EXEMPTION FROM WORKERS BUILDING
COMPENSATION INSURANCE ADDRESS rG7f STATION DEPTH!
(This se i torn need not be completed If the work Involved by theWANHOLE REFERENCE UPPER
permit Is for one hundred dollars ($100)or less ) LOCALITY
I cMlfy that in the performance of,the work fw which this QST - LYNl OF CONNECTION teNcnN rRwS
permIt Is Issued, I shall not employ any person In any manner v CURB PL ASL TOPL
so'at to become subject to the Wwken Compensation Laws No
OWNER - CO uAR Roe N
MOUL
Date Applicant ADDRESS TRUNKvmwT URD ROAD PEYHJi ND
NOTICE TO APPLICANT If, after making this CNrnficate of CIY TEL NO RC01M(EaCN
wAwTR BASEMENT RECORD INSTR NO DATE
Exemption, you' should.become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCBPrON LOT No
comply with such provisions or this permit shall be deemed wtnNiw
revoked BLOCK TRACT ROACXMEM V
LICENSED CONTRACTORS DECLARATION NO OF NDGS
I hereby affirm that I am licensed under provisions of Chapter �OF
LOT NOW ON Lor '
9 (commencing with Section 7000) of Division 3 of the Busy USE JGS �-
ness and Profs ions Code and my license Is In full force and CHARGES
effect CONTRACTOR ION CHARGE FEE
License Number5�lSS ,s, //y� is Class C--Yz ADDRESS
Contractor,ftM►+ XW_I/-iDate /3/Q� CITY TEL NO / /—ZNpO c P❑ 1 am exempt under Sec of the L A Co L�NSE NO tt� _Plumbing Code and/or Sec ofthe No DESCRIPTION OF WORK RE'OUSE SEWER CONNECTING TO „—a q VALIDATIONB 8P Code for the following reason PUBLIC SEMIR ryeDate O Pits R SE CONORAINEm OR /!L/'r" `
COLAs autR COwrECTr+a ro
NA
Slgnatur CONNECT ADDIIDNAI BLDG OR ,
WORT(TO HOUSE SEWER
OWNE -BUILDER Dfi RATI N o
I hereby arm that I am exempt from the Con roc Dr's License RAJNIHELD
ExTN Py °
affirm L vANNI _
Low for the following reason (Secton 7031 5, Bunness and Pro- ALTER REPAIR ABANDON iu
fessNons,Code) DISPOSAL
❑ I,as owner of the property,or my employees with wages as ANTA
r
their sole compensation, will do the work and the structure i _ � p
Is not Intended or offered for Sale (Section 7044, Business Permit f d0 33071 ITEMSo4. 0
and Professions Code) OWNER'S
❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE
licensed censed contractors;to construct the project (Section 7044 i HAVE AT THIS DATE A CONTRACT WM4 THE HERENN�NAMm CO oR ro TOTAL 34 . 50
Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER
CONSTRUCTION LENDING AGENCY LACK 3,r.50
I hereby affirm that there IS o•construction lending agency SIGNED THIS DAY OF 19_ PiloCLIALUT
for the performance of the work for which this permit S OWNER OR lN4VVTntS�
Issued (Sec 3097, CivONTERS AGENT C )
I
ADDRESS
Lender's Name OD00-DWI 12/13/90
Lender's Address 4455 1 AM 9:17
1 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 laws regulating Plumbing and Sewer,
and hereby authorize representatives of this County to enter
upon the abov3Wiention operty for Inspection purposes / I
SI Lure of Per I DtK Ifa REVE6E POR EXPLANATORY LANGUAGE
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