HomeMy Public PortalAbout5082 SERENO DR_Sewer__ WORICERS COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
msule or p certrfimte of Wwken Compensotwn Insurance, or 'a1°'ro
'a eestified c 'y Cher f(3eD 3800 Lab� , °° °mvft APPLICATION FOR PERMIT -
PoltcylJo ,Compony s17'P7� fir—../' •
,LJ•/Ce�ufied copy is hereby furnhhsd SEWER - SEWAGE DISPOSAL
❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department
Date 17/3/%0-Appltccn1 &,,-4 lVic-on 4�s..z— FOR APPLICANT TO FILL IN CONNECTION DATA
/CERTIFICATE OF EXEMPTION FROM WORKERS' euaprx;
COMPENSATION INSURANCE ADaEas Z STATION(This section section need not be completed if the work involved by theMAroHaE RHERENCE UPPER
LOCA
J."is for one hundred dollars ($100)or less ) LOCm R
I cern that in the ormince of the work for which this �yrs WK a CDnHEcriar UNGnt FROM
certify Perf Y Clete P L M t TOP L
permit Is owed, I shall not employ any person in any manner PC NO
so os to become subject to the Workers Compensation Laws OWHIR CO iMP Ho J106HO
r rLISE�
Date Applicant TRAFFIPAVIT RECORD
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NOTICE TO APPLICANT If after making this Certificate of m NO AEPgAvir wArvDH FASFMFM xCORD iNSTR EED aArE
Exemption, you should become subject to the Workers'
Compensation provisions of the Labs code, you must forthwith ON for FSD
comply with such provisions or this permit shall be deemed Pnvr cesr � �
revoked TRACT STATE ENCRCACPUEENr f
LICENSED CONTRACTORS DECLARATION PEW[r HO
OT �ca LOOT
1 hereby off irm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Bust- S CHARGES
nen and Professions Code, and my license is In full force and -
effect rA
TR �ilt ( CONNECTION CHARGE EEELicense Numbeer.5` F�'SSLit Class ContractorAzlg �/.'yr�i Date L- MATE L ND / �� DISTRICT NO GROUP sii PGpYI am exempt under Sec of the L A Co +oPlumbing Code and/or Sec of the DESCRIPTION OPWORK FEE RMq
�co"acnNG TO a� DATE/_•7s9/ VALIDATIONB 6 P Code for the following reason CvaE•TAAR PH OR
PITNK I
Dote rJ O SE SEWERo/OR DRAR6HD BYOEtsE SEWER CONNFCTNO ro rotoeLac OR
OpR ER-BUILDER TI WORK TOVERROO HOLISE SEWERSEE ��I hereby affirm that I am exempt am the Contractor n License TH ORYsvHt MANIHpFlaw for the following reason (Sectors 7031 5 Buianess and Pro LTDt @PAHOUSE 10
fenions Code) _ WER OR DISPOSAL SYSTEM
❑ 1,oa owner of the property,or my employees with wages as AC(T.i
their sole compensation will do the work and the structureY�07 �� ��
Is not Intended or offered for sole (Section 7044, Business P9EfTllf f 1 ITEtlS
and Professions Code) WNER'S '�❑ I,as owner of the property,am exclusively Contracting with ORIZATION TOTAL FEE �t _,Llicensed contractors to construct the project (Section 7044 AT THIS DATE A COHRRACIF WITH THE HEREIN HAMm CON RACTORTOTOTS 34 . 5p
Business and Professions Code) r THE ABOVE DESCIaeED EXIMIHG D•MEU1HG lO TPE PDUIC SEWER (� l
CONSTRUCTION LENDING AGENCYhereby affirm that there u o construction lending agency THIS DAY OF19_ j]Q
for the performance of the work for which this permit is ce ,
amrEwws AGEH1
rowed (Sec 3097, Civ C ) � ,
Lender'°Name ADDRESS 0000-0001 12/13/90
Lender's Address - 4453 1 AM 9116
I certify that 1 have read this application and state that the s
above information is correct I agree to comply with all County
ordinances and State lows regulating Plumbing and Sewer, ,
and hereby authorize representatives of this County to enter i
upon the above-m boned property for inspection purposes
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ign r of Per lee Date TEE REVERSE FOR EXPLANATORY LANGUAGE