HomeMy Public PortalAbout5080 SERENO DR_Sewer__ WORKERS COMPENSATION DECLARATION
I hereby affirm that 1 have a certificate of consent to self '
insufe, or a certificate of Workers Compensation Insurance, or 1D
'a certified CS T�Tv f(Sec 38001 Lab C ) ��DPW WM APPLICATION FOR PERMIT
Policy Nom,+ . .company Cmzzz .x_✓ I
SEWER - SEWAGE DISPOSAL
Cemfied copy is hereby furnished
❑ Candied copy is filed With the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department
Date 3 Applicant �qs � -�� FOR APPLICANT TO FILL IN CONNECTION DATA !�
'CERTIFICATE OF EXEMPTION FROM WORKERS' twILDINc
, COMPENSATION INSURANCE ADI1RE55 GAS(o STAIgN DEPTH
(This section need not be completed if the work involved by the REEfltEHa UPPER
permit is for one hundred dollars($100)arjess ) LOCALITY L
I certify that in the performance of the work for which this HIEARE5CROSS ST - TYPE OF CONNECTION GNGM TRW )
permit Is issued I,shall not employ any person in any manner CURB Pt ML TOPL
SO as to become iubject to the,Workeri Compensation Laws P c NO
(YA'tER CO(b IMl NO JOB NO
• J
MAIL
MUMS PERMIT NO ROAD PERMIT NO
Date Applicant
NOTICE TO APPLICANT If, after making this Certificate of M No $2— '
DAWT WAlvsi EASEMENTRECOILDNO DATE
Exemption, you should become subject to the Workers' -
Compensallon provisions of the labor code you must forthwith LOT rO HwY comply with such provisions or this permit shall be deemed � WIDENINGrevoked h TRACT �ICROACKMENT
No OP BLDGS NOLICENSED CONTRACTORS DECLARATION NOW ON LOT
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Bust- CHARGES
ness and Professions Code and my license is in full force and effect aWrRACTOR r ECTTON CHARGETEFLicense Number 52,&STAt Lie Clan C'�iss ZreFControctor`{d'f/�rx�s.r Date � SJ an AulCis� m NO 7/ / ICT NCI GRouP MAP //SK � m By ZO
STALE UCDO - //
1 am exempt under Sec of the L A Co FATE NpUCPlumbing Codeand/or Sec ofthe DESCRIPTION OF WORK FEE wUSE SEWER C010ECTIEG TO f_a VALIDATIONB 8 P Cade for the following region PUBLIC SEWER E�Z3/9H AME sEEPAOE Pn 11-Dote NIS MO/OR DRAIWK D V 411�..IE�!IIOI/5E SEW2R mtdECr TO `/ C..� ''Vr V
PR VA
Signature P CO RK TO HOUSE
SEADDITIONAL BLDG OR ►
O R-BUILDER DE TI f WORKroHIousE SEWer '
OVERFLOW AGE NT DRATNPIED
I hereby affirm that I am exempt from a Contractor's License Exna CESSPOOL,DRYWELL MANOU! '
HwY
Law for the following reason(Sacton 7031 5, Bulsnen and Pro- ALTER REP"04 HOUSE 10
factions Code) SEWER OR DMP0SAL SYSTEM A, I
❑ 1,as owner of the property,or my employees with wogs as - ACCT.i
their sole compensation, will do the work and the structure - 3M7'
Is not intended or offered for sale (Section 7040, Business
and Professions Code) OWNER$ Permit f 1 11uis
❑ 1,m owner of the property am exclusively contracting with AUTHORIZATION I TOTAL FEE TOTAL 34 . 50
licensed contractors to construct the project (Section 7004 I HAVE AT THIS DATE A CONTRACT WITH THE HEAEN NAMED OONTRACIOR TO - _
Business and Professions Code) CONWECT THE ABOVE DESCRIBED EXISTING DWE1rNG TO THE PUBLIC SEWER CHECK
� 9)
CONSTRUCTION LENDING AGENCY _ �L.LET1�L�1.�1�
fl
hereby affirm that there Is a construction lending agency SIGNED THI$ DAYOF 19_ owe ,Oct
for the performance of the work for which this permit Is OWNER OR
Issued (Sec 3D97, Civ C ) owt40R.s AGETvr
Lenders Name ADDRESS 130011-131301 12/13!9O
Lenders Address . +456 1 AM 9:17
1 certify that I have read this application and state that the
above Information Is correct I ogres to comply with all Count' i
ordinances and State jaws regulating Plumbing and Sewers, -
and hereby authorize representatives of this County to enter _
upon the above-menti ed property for inspection purposes
Signal o ermines Date TER RRVERSE FOR EXPLANATORY LANGUAOI ,