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Home My Public Portal About5111 SERENO DR_Sewer__ WORKERS COMPENSATION DECLARATION p005t DPW BrBB I hAreby affirm that I have a certificate of consent to self X0051D Insunb Or a certificate of Workers Compensation Insurance or . c Ilfied a 1 n of Sea 31100T�TT �� APPLICATION FOR PERMIT Par cy No lompany tr Certified copy is hereby furnished SEWER - SEWAGE DISPOSAL ❑ Certified copy Is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY departure � � � ( + s Date _ , phcont S1" (-�/Y/�/ ��AOK FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS BUILDING Q COMPENSATION INSURANCE ADDRESS STATION DEM. (This section need not be completed If the work Involved by the LOCALITY MANHOLE REFERENCE i PPE r permit Is for one hundred dollars ($100)or less ) TYPE OF caNNECigN om I certifythat In the performance of the work for which this NEAREST - - TENGTH FROM Pe GROSS ST r CURB P L MI. TOP t permit Is Issued I shall not employ any person in any manner LEGAL Pc NO so as to become subject to the Workers Compensation laws DESCRIPTION Loi NO CO IMP FRO 10B NO BLOCK TRAGI TPUNt KRMIT NO ROAD PERMIT NO Date Applicant NOTICE TO APPLICANT If after makin This Certificate ASSIESSO11 AFFIDAVIT wuvER EASEMENT RECORD IrvSrR NO DATE g MAP BOOL( PAGE PAFK.EL Exemption you should become subject to the Workers NO OF BL IZEDGS Compensation provisions of the Lobar<OdG you mU51 forthwith SOF LOT NOW ON LOi HWr OR Sr WIDENING comply with such provisions or this permit shall be deemed USE OF revoked EIUILDINOBSTATE ENCROACHWN1 LICENSED CONTRACTORS DECLARATION % PERMIT No I hereby affirm that I am licensed under provisions of Chapter OWNER til 9 (commencing with Section 7000) of Division 3 of the Buss MAIL CHARGES ness and Professions Code and my license is In full force and ADDRESS effect CITY L NO 00 ONNECTION CHARGE FEE License Number-&�ILI x be Class 1� u h REIMSURSEMFNT FEE CONTRACTOR .� _ ,` F Contractor Dote ADDRESS 3 � 9 DISTRICT rqJP Bx MAP FC PROCESSED By > ❑ I am exempt under Sec of the L A Co 4 z 0� 9 d CITY — EL NO O O Plumbing Code and/or Sec of the STATE IuG - FINAL IC1 LICENSE NO UASS DATE Ll I VALIDATION O B $ P Code for the following reason NO DESCRIPTION F WOM FEE 2, Date HOUSE SEWER CONNECTING TO FINAL PUBLIC SEWER Br SEPusW .fes PNC TANK SEEPAGE OR a fl $IOatUf@ MET AND OP DRAINFIE LD ID A NrCTIMG r0 i0 OWNER BUILDER CLARATION w 'E5DwRcopoll I hereby affirm shot I am exempt from the Contractors License CR NECr ADDITIONAL BLDG OR WORK r0 HOUSE SEWER a Law r the following reason ($ecton 7031 5 Bulsness and Pro A�.� .sr f@5]I ns Cade WERE OW SEEPAGE PIT GRAINFIELDMH - 2 ) f1IIN Gfssrool DRYWFII MANHIXE Tfl'] VL.30 as owner of the property or my employees woh wages as Ay TER REPAIR OR ABANDON HOUSE JJVJ SEWER OR DISFOSAL SYSTEM I ITEMS they sole compensation well do the work and the structure Is not Intended or offered for sole (Section 7044 Business and Professions Code) TOTAL 82 -3101ElI as owner of the property am exclusively contracting with Permit S }� ' 111 licensed contractors to construct the project (Section 7044 OWNER'S l �Q 92 Business and Professions Code) AUTHORIZATION TOTAL FEE CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONIFACI WITH THE HEREIN NAMED. CONTRACTOR TO ► I hereby ofbrm that there Is o construction lending agency CONNECT THE AEOvE DESCRIBED EKISIING DwRING r0 THE PUBIC SEWER for the performance of the work for which this permit Is Issued (Sec 3097 Civ C SIGNED THI$ DAY OF 19_ 0000-0001 6/27/95 27/DI` ROR Lender s Name OHNFR5 AGENT 1055 I AM 8:48 Lenders Address ADDRESS I certify that I have read this application and vote that The above Information Is correct I agree to comply with all County ordinances and State laws regulating Plumbing and Sewers and hereby outhorlze representatives of this County To enter upon the above mentioned property for Inspection purposes Slgno re of P rmitte Dale T SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS COMPENSATION DECLARATION so.WST DPW 6M I hereby affirm that 1 hove a certificate of consent to self zeABQD U Insure GE a cerrficprp of Workers Compensation Insurance or P licy N d copy thereof (Sec 3800 Lab C , - - APPLICATION FOR PERMIT Polley No - Company + ❑ Certified copy is hereby furnished SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS BUILDING COMPENSATION INSURANCE ADDRESS �/� STATION DEPTH (This section need not be completed if the work involved by the DUTY MANHOLE PEFERENCE uPEt c permit is for one hundred dollars ($100) or less ) LE WFEU CONNECTION NEAREST UNDI FRpV. I certify rho, m the performance of the work for which this CROSSST r CURB PI ML Toot permit is Issued 1 shall no, employ any person in any manner so assto�become su�blect to the Workers Compensation Laws DEE�RviroN LOT NO CO IMP ND JOB No Dpl��Zplcom �H+��-�aw/•� B LOCK p TRACT TRUNK PERMIT NO ROAD PERMIT NO NOTICE TO APPLICANT If after making this Certificate of pOK �•�p ! PAGEO/7 d/ AFFI DAwr wAiV1R EASEMENT aECOaD INsra rq DATE EL Exemption you should become subject to the Workers PARCEL Compensation provisions of,he Labor code NO OF BLDas pe p you b forthwith F LOT Now ON Lor Hwr OR sr WIDENING comply with such provisions or ,his permit shall be deemed USE OF revoked - BUILDINGS x SLATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION PERMIT No I hereby affirm that I am licensed under provisions of Chapter R u- GC 17 7417 9 (commencing with Section 7000) of Division 3 of the Bus+ ' CHARGES ness and Professions Code and my license Is in full force and ADDRESS effect A I ^r -1 �LL CONNECTION CHARGE FEE License Numrbe-. ✓✓ lac Class14"1 / ��d REuneuCT Nir FEE CONTRACTTYLLiI_w Date �/ � F ESS TOR { T15 � SJ, BK RG COnnattor DISTRICT NO GAWP AUP ESSED Br } ❑ 1 am exempt under Sec of the L A Co J_ �D� 70171 a O ;- TEL N (! O Plumbing Code /or Sec of the E NNAt Cy CLAss DATE 1�" VALIDATIONOB 8 P Code or he fallowing reason DESCRIPTION OF WORN FEE k HOUSE SEWER CONNECTING TO FINAL f Date PUBLIC SEWER BY W SEPTIC TANK SEEPAGE%T OR n Slgna,We PITS AND OR DRAWFIELD (n B TIDE RA ION PRIVAI HOUSE SEWER CONNECTING TO , 2 DI SYSTEM I hereby affirm that I am xempt from the Contractor s license CONNECT ADDITIONAL&D`3 OR �Es Low for the following reason (Secton 7031 5 Bu+sness and Pro WORK TO HOUSE SEWER 2301 154.00 fessions Code) OVERROW SEEPAGE PIT DRAINF frTN CESSPOOL ORYV4LL " D E ❑ 1 as owner of the property or my employees with wages as ITER PEPua oa ABANDON HO s Their sole compensation well do the work and the structure SEWER OR DISPOSAL SYSTEM VI - is not Intended ar offered for sole (Section 7014 Business and Professions Code) 1 fF (3(3 El as owner of the property am exclusively contracting with Permit S TOT " licensed contractors to construct the project (Section 7011 OWNER'S Business and Professions Cade) AUTHORIZATION I TOTAL FEE 4010 /ry�k�r�(ryy// ( (LFL CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WTIH THE HEREIN NAMED CONTRACTOR TO /OFM 154.00 1 hereby affirm that there is a construction lending agency CONNECT THE ABOVE MK91UD EXISTING DMILING TO THE PUBLIC SEWER , srfB'R111L -� for the performance of the work for which this permit is Issued (Sec 3097 Civ C I SIGNED THIS DAV OF 19_ OWNER OR lender s Name OWNERS AGENT ADDRESS I1f�„ ___1 Lender s Address I q�� p I ceNif that I have read this application and state that the 1 'y� abov formation is correct I agree to comply with all County ordi a es and State laws regulating Plumbing and Sewers an h reby authorize sentatives this County to enter u e abole odd ropert f pection purposes ig a I Date SEE REVERSE FOR EXPLANATORY LANGUAGE