HomeMy Public PortalAbout5113 SERENO DR_Sewer__ WORKERS COMPENSATION DECLARATION p ODet DPW 6111911
hereby affirm that I have o cereficote of consent to set/ LI
Insure a, a certificate of Workers Compensation Insurance or 76ABE2D • '
a certified Ca y t�@r � pony C I� .��A�, APPLICATION FOR PERMIT -
Policy No
L1Certified copy 1s hereby furnished - � ' •' `. , SEWER ,, SEWAGE DISPOSAL ,
❑ Certified copy is filed wnh the county building Inspection o"- COUNTY OF LOS ANGELES, BUILDING AND SAFETY ,
department pp��/��I([[[[[����� � 1 ,= - 1111 - `J, V r .0 '
Date-A4 1—�ppllcont r �A�IJ lam`/ VN�EA�ST
R APPLICANT TO FILL IN CONNECTION DATA
CERTIFICAT OF EXEMPTION FROM WORKERS _COMPENSATION INSURANCE STATION - DEPTH
(This section need not be completed if the work Involved by the sA1ANI+OIE REFERENCE [ uroEapermit Is for one hundred dollars ($100)or less ) Tvx OF CONNECTION LENGTH FROMcertify Ih01 In the performance of the work /Or which this r ' CURB PL ML TOPL
permit Is issued,) shall not employ any person m any manner PC NO
so as to become subject to the Workers Compensation Laws LOT NO CO"TMP NO JOe NO
BLOCK TRACT TRUNK PERMIT INC) .. ROAD PERMIT NO '
Dote Applicant
A59ESSOR INST4 NO DATE
NOTICE TO APPLICANT If after making this Certificate of MAP BOON J PAGE O L PARAFFIDAVIT WAIVER EASEMENT RECORD CEL OI
Exemption you should become subject to the Workers _ NO OF BLDG
Compensation provisions of the Labor code you must forthwith BizE OF LOT S Ax ( L Now ON LOT HWY ORST WIDI
comply with such provisions or this permit shall be deemed LISF OF
revoked • BUILDINGS STATE ENCROACHMENT -
LICENSED CONTRACTORS DECLARATION PERMIT No
I hereby affirm that I am licensed under provisions of Chapter OWNER
9 (commencing with Section•7000) of Division 3 of the Busi MAIL
CHARGES
AOORE95
ness and Professions Code and my license Is In full force and 7
• effect - 2 CITY TEL NO --O ,1
CCNECTICN CHARGE FEE i
License Num//ber����, ```��� L ccClass (J q REIMBURSEMENT FEE
Controctw 7Y J r4-A) .+� �y /—{ RESS CONTRACTOR
DISTRICT NO GRCUP MAP PROCESSED BY
ADDBA PG
❑ I am exempt under Sec of The L A CoD� -:3
a
QTY TEL No UO
Plumbing Code and/or Sec of the STATE tic FINAL
LICENSE NO CASS DATE VALIDATION Z
B 8 P Code for the following reason NO DESCRIPTION OF WORK FEE 1 I(� �V' O
' HOUSE SEWER CONNECTING TO ./) F
,Dat@ PUBLICSEWER ' H / D FINAIBY W
PITS A TANK SEEPAGE FITLD OR
Signature .J7/� -�//x-�•�/ SEM AND K SEEPAGE LD
LARATION HOUSE SEWER CONNECTING To
IL
PRIVATE DISPOSAL SYSTEM
I hereby affirm that I am exempt from The Contractor s License CONNECT ACCITICNAL BLDG OR
OWNER BUILDER D71 lU
Law for the following reason (Secton 7031 5 Buisness and Pro WORK TO HOUSE SEWER 50
fessions Code) , EEATN LoiSs DRYWE�AM1UNLHOLE — - � I
1 I-EI13
❑ I as owner of the property or my employees with wages as A1TER REPAIR OR ABANDON H SE i
their sole compensation will do the work and the structure SEWFR OR DISP L SYSTEM TOTAL 71 . 10
Is nor'Intended or offered for sole (Section 7044 Business CHECK 71.lil
'and Professions Code) t
' ❑ I as owner of the property am exclusively Contracting with OWNER'S Permit f Q CHWIE A0
licensed contractors to Construct the project (Section 7044 }
Business and Professions Code) AUTHORIZATION TOTAL FEE /
• CONSTRUCTION LENDING AGENCY I HAvE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRAOOP r0 , Q[J�i}—Q 1 7/:5/9o,I hereby affirm that there is O construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DNEUwG TO THE PD&IC SEWER
for the performance of the work for which this permit is 6197 1 ANE:49
or the
3097 Civ C ) SIGNED THIS DAY OF E9_
OWNER OR
Lender s Name , OWNERS AGENT
Lender s Address ADDRESS
I certify that I have read 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 authorize representatives of this County to enter
upon the above lmee_ntionedd property for Inspection purposes((
$Ignature of Perm mee Date � SEF REVERSE FOR EXPLANATORY LANGUAGE r