HomeMy Public PortalAbout5100-5102-02 1/2 SERENO DR_Sewer__ WORVRS'COMPENSATION DECLARATION 76AG420
CE 806 (260) APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self SEWER-SDISPOSAL
Insure or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(See 3600 Lab C) COUNTY OF LOS ANGEL BUILDING AND SAFETY
Policy No Company
i
Certified copy 6 hereby furnished FOR APPLICANT TO FILL IN CONNECTION DATA
ADDRESS.-
Certified
SS B ���,•O trwTloN OCPTN
Certs ied copy Is filed with the county budding Inspection wUI Leas yt uRPCR
department LOCALITY MANHOLE REFERENCE
l LOWER
Date— Applicant • - NEAREST ' TYPE OF CONNECTION LENGTH FROM
CERTIFICATE OF EXEMPTION FROM WORKERS CRoaa ar p O� r CURB P L M L To P L
COMPENSATION INSURANCE (� `Q P C NO
OWNER l:/ ej ` CO IMP No JOB No-Bli ,
M
(THIS section need 110[ be completed J the work mvolved - woAIL
n REee Z TRUNK PERMIT NO ROAD PERMIT NO
by the permit u for one hundred dollars ($100) or less) ,DAVI
CITY s D IN.TR n DA,.
L NO AN �-
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1 certify that In the performance of the work for which this LEvw
permit Is Issued 1 shall not employ any person in any manner DESCRIPTION LOT NHWY OR ST WIDENING X
so as to become subject to the Workers' Compensation Laws 0
j. �//O1BLOCK TRACT y - VE4 STATE UNCROACHMENT F
Date&O iZ-OZApplicant_ J41Xrr t4 J` ? NOBLDOE PERMIT NO (J
NOTICE TO APPLICANT If, after making this Certcate of SIZE OP LOT now N LOT LU
Exemption, you should become subject to the Workers use OF BUILDINGS eHw ea Z
Compensation provisions of the Labor Code you must forth `
with comply with such provisions or this permit shall be CONTRACTOR 1< I• CONNECTION CHARGE FEE
deemed revoked V
LICENSED CONTRACTORS DECLARATION wvvxcae /-!"I REIMBURSEMENT FEE
onrwlcr no cnoUP MwP a c o.D.r
1 hereby affirm that I am licensed under prDivovisions 3 of Chapter Derr EL No
9 (commenting with Section 7000) is nse is in 3 of the Bust 9TwrU uC 77 OO
ness and Professions Code, and my license Is In full force and Llcexee n 7L CLw9a —J rLL 7�
effect
3¢ DESCRIPTION OF WORK FEE
License Number' 7 Lm Class " ✓ feMHp coxa ecTlxc To FINAL VALIDATION
/� DATE
A/ 7WY/0,? LL q �:.;e TANK ON
Contractor Date__�f�-O` _� n.wnDjon D FINAL `
Hou.. e.R..COIN...TING o BY
❑ Poxvn.c ow.Po.wL.r.TEM T R
I am exempt from the licensing requirements as I em a c T ..IT0.. PLOa o
licensed architect or a registered professional engineer RE1»�Hou.. ....ER
acting In my professional capacity (Section 7051, BusEwPLOR..vwoE Pn OR C
lopO
cu.PooL oxrrreLL AM `tea ' Ca//
s and Professions Code) i.TxROAIR ew . OUSE
w ow o oouL ..TEN N ,
Lm or Reg No Date
HOME OWNER BUILDER DECLARATION
1 hereby affirm that I em exempt from the Contractor's
OWNER'S Permit s
License Law for the following reason (Section 7031 5, Butt AUTHORIZATIONI TOTAL FEE
ops and Professions Code) E AT THIS DAYR w ERRIN NAMED c
❑ ..cTow To Can...T ..CONTRACT nND ow.wwa
I as owner of the property will do the work and the THE Hu.LIc ..W..
T
structure Is not Intended or offered for sale (Section SIGNED THIS DAY OF 19
7044, Business and Professions Code) OWNERo
ORN.R.A... T 2 4 3.6 A
CONSTRUCTION LENDING AGLNCY • • ' 0
I hereby affirm that there Is a construction lending agency
for the performance of the work for which this permit Is
Issued(Sec 3097,Civ C) 21B E•2 a 0 0
Lender s Name - a a Is 28005
Lender's Address
I certify that 1 have read this application and state that the I 0 0 2—8 0
above Information Is correct 1 agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers
and hereby authorize representatives of this County to enter
upon the above mentioned property far Inspection purposes
!D-2tro SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature of Perm ee Date