HomeMy Public PortalAbout5120 SERENO DR_Sewer__ WORKERS COMPENSATION DECLARATION �.
I hereby affirm that I have o certificate of consent to self Q
Insure or a certificate of Workers Compensation Imuronce or IIS
a certified copy thereof(Sec 3e00, Lab C , CE"�REV iMl APPLICATION FOR PERMIT 0
Policy No company SEWER - SEWAGE DISPOSAL -
❑ Certified copy a hereby furnished � � `
❑ Certified copy is filed with the county budding inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
deportment
Date 4 Applicant FOR APPLICANT TO FILL IN / CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS L IE�d D�
COMPENSATION INSURANCE ADDRESS /�` O E 7w STATION aI
(This section need not be completed if the work Involved by the LouLlry �� hoc.& �`.l--x-- MANHOLE REFERENCE � ' � LOWER
permit is for one hundred dollars($100)or less ) _ '
TYPE amH
I certify-that In the performance of the work for which this tR0555T gvr/f6•fU7 L✓�. v CURB
�1 vl M�ro•L�t
permit is issued 'I shall not employ any portion in any manner
so as to become subject to the Workers Com ensist Lawa C NO
L, I OWNER�IpA-rL -G^or-DL742t3 COm uw r+o � loo ra
Dora•] —/—'`/ Applicant ✓ ADDRESS /020 E. afiD wt'4� TRIWx PFAAVTNO % ROAD PRMR NO
NOTICE TO APPLICANT If aper making this Certificate of a`Y`TV vyi10L#- G4rf& NO AFNDAVIF wA1VER EASEMart RECORD INSTR NO DATE
Exemption, you should become subject to the Workers' LEGA1 1
Compensation provisions of the Labor code you must forthwith DESCRIPTION LOT NO HWY MST WIDENING
comply with such provisions or this permit shall be deemed
revoked BLOC(( TRACT STATE ENCROACHMENT -
LICENSED CONTRACTORS DECLARATION NO OF BLDGS °ERwr}NO
I herebyoffirm that I am licensed under UEE OF Lor �S K SVA Now ON LOT e ,
provisions 3 of Chapter WI of [Li �(r
9 (commencing with Section 7000) of Division 3 of the Bull eulLDlrvcs �M� CEiARCis
ness and Professions Code and my license is in full force and
effect wNTRAaoa��JJ✓fl(�.�`- CiT�>FS Pt66• coeiHECTIorLCHARGE FEE
License Number712 yd 3`L'ic,Clara C—.� ADDRESS /.O• �oX �'frj' REiMBURSEMEM y
ControctonE��4� 61r(? /" S/-� TEL NO 3S'Ai /7
DISTRICT ry GRIXN MAP PROCESSED er O
clrr ill/Lt C�7"- 1 Sl V
❑ I am exempt under Sec of the L A Co TATE iq ;f 2 YG3 LIC ��31♦i �/o
g 3 PG
Plumbing Code and/or Sec of the NO DESCRIPTION OF WORK PEE FINAL
HOUSE SEWER CONNECTING TO DATE _ V U� VALIDATION 6
B 8 P Code for the following reason PUBLIC SEWER Q V�
SEPTIC Aid( SEEPAGE PIT OR
Oats
MTS AND/OR DRAINFIELD 4J G
HMM SEWER CONNECTING 10 By
Signature CONNER AITDILgNA&OG OR
OWNER-BUILDER DECLARATION woRX TO HarsE SEWER
I hereby affirm that I am exempt from the Contractor s License OVERFLOW SEEPAGE PIT DIUU_W LD
WN CEssPOa DRVWEIL MANHOLE
Law for the following reason (Secton 7031 3 Bulsness and Pro- ALTER REPAIR OR ABANDON(LOUSE �V 7 7a
fesslons Code) SEWER OR DISPOSAL SYSTEM
I
❑ j,as owner of the property or my employees with wages mfJ l Ela
their sole compensation will do the work and the structure Q'•t• z l
is not Intended or offered for Sale (Section 7044, Business
and Professions Code) OWNER'S Permit S �' ' ' 21 cJ Q=o
❑ I m owner of the property am exclusively contracting with AUTHORIZATION TOTAL FEE 0 5 0 8—8'4
licensed contractors to construct the project (Section 7044, i HAVE AT iH1a DA1F A CONTRACT WITH THE HEREIN NAMED R TO '
Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER
CONSTRUCTION LENDING AGENCY p
1 A�
hereby affirm that there is a construction lending agency SIGNED THIS DAV OF Itr 4/ ►
for the performance of the work for which this permit is owrrER OR
issued (Sec 3097 Civ C ) OWNERS AGENT
ADDRESS O 0 eL C
Lender s Name
Lender,s Address
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 authorize representatives of this County to enter
upon
�tthha_pbovs- eention property for inspection purposes
Signature of Permlhee Dara SKI IIIIEV6lfE FOR EXP AFIATORY LANGUAGE