HomeMy Public PortalAbout5084 SERENO DR_Sewer__ WOOkERS'COMPENSATION DECLARATION
(Ii, I helabr arffnrm"That I have a certificate of consent to self
!Fpure nr a cer+illnxte of Workers Compensation Insurance, or M64420 ,t
PcAi4fortified f (�` 3800•T�exz � n°°�°"""" APPLICATION FOR PERMIT IIul1
�Pdicy ca,npan,, SEWER - SEWAGE DISPOSAL Li
Certified coN'ts hereby furnished
❑ CenifHsd copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department
Date Applicant FOR APPLICANT TO FILL IN n' CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE , �Atffi Q STATION DO" -
(Tho section need not be completed if the work involved by the uPFER
OCALm
permit is for one hundred dollars($100)w less ) LAtAr+r01E REraLOWER
rEAusr - - -, TYFE OF(CONNECTION LENGTH FRcw
i1 permit
that in the performance of the orlon for which ilio CROSS eT y CURB PL ` ASL TOVL
permit is issued, I shall not hemploye Workers'
any Conon in any manner F C NO
so as to become subject to the Workeri Compenaahon Laws OWNER - CO W NO toe NO
Dots ' Applicant ADDRESS
NOTICE
;STA
ERA1n NO ROAD PFRADT NO
NOTICE TO APPLICANT If, cher making ilio Certificate Work of - ant TE NO T
AVIT WAIVER EASEAEENT RECORD MR NO DATE
ExemptionCompensation
your should become subject o the Warners' LEGAL
c om lirua h provisions of the labor coder, You must forthwith DESCRIrnpa LOT NO comply with such provoions.or ilio permit shall be deemed � wro[NrEc
revoked BLOCK TRACT ROACHN09
LICENSED CONTRACTORS DECLARATION
NO OF NDca O
I hereby affirm that I am licensed under provisiom of Chapter USIECIF lar now Or+lar
usE O
9 (commencing with Section 7000) of Division 3 of the Bust- - BUILDINGS oingGEg y
neo and Professions Code, and my license is in full force and
effect CONTRACTOR r TION CHARGE FEE '
License Number ,Lic Clog C"i�2� m
ADDRESS
Contractor-���.+�wr irate__[� � aTy m _ r FK) cRam M F,w FwaStilD er PG
❑ I am exempt under Sec of the L A Co LICIVISE NO CLC`ASs Z Q 7/ND DESCRIPTION OF WORK RE PlumMng Cade and/or Sec of the FausC sEw>R mNFEcrINc To Z VALIDATIONZB 8 PCode'for the following reason I R101IC YWFR
//j/s 5[!P Rf ORDan, Z � RIS AID/OR pWNRE1D
I^— HOuse SEWER!CONNECTING To
PRIVATE DISPOSAL SYSTEM
S gr _ ` CONNECT ADDMONAL BUIG OR Pilov OWfI R- UIL)E N WORK '
I hereby affnm t lam esempt from the Contractor's Liceroe WIN ALANHou
Low for the following reason (Secton 7031 S, Buoness and Pro- uTER REPAIR OR HOUSE 1(f
fiessi om Code) sEweh OR DISPOSAL sysrBW
AiGT.•.
❑ I,as owner of the property,rn my employees with wages m
their sole compensation will do the work and the structure 3307 34.71
is not intended w offered for sale (Section 7044, Business
and Professions Code) _ OWNER'S Permit S 1 ITEM,
❑ I as owner of the property,am exclusively contractingwith AUTHORIZATION TOTAL FEE
+ licensed contractors to construct the project (Section041 1 HAVE AT TIS OAR A CONTRACT WIN THE HERERN NAMW CONTRACTOR TO ' TOTAL 34 - 50
Business and Professions Code) CONNECT THE ABOVE DESCRIBED EwsTING D'A'EILRNG To THE FuxIC SIMI R + CHECK '4,51)
CONSTRUCTION LENDING AGENCY -
1 hereby affirm that there is a construction lending agency SIGNEDTHIS DAYOF 19_ , CHAIJ� .Ci[I
for the performance of the work for which this permit o OWNEOR
R
Issued (Sec 3077, Civ C ) oW+aaS AGENT '
Lender's Name ADDRESS 0000-4001 VJ13M
lender s Address -
4452 1 AM 9:1L.;
I certify that I have rood this application and state that the
above information is correct I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers,
and hereby outhwize representatives of this County to enter
upon the abovE Pntionsd property for inspection purposes
Q,. / —
SI Lure of Pw s0lamDote BTU REVERSE FOR EX►LANATORY LANGUAGE