HomeMy Public PortalAbout5233 SERENO DR_Sewer__ 11
WORKERS COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self 210051 DPW BIBS
Insure or a certificate of Workers Compensation Insurance or 78AMM
a cerNfl!�copy thereof (Sec 3800 Lab , _. APPLICATION FOR PERMIT
Policy No Company SEWER - SEWAGE DISPOSAL
Certified copy Is hereby furnished
Certified copy is filed with The county building inspection COUNTY OF LOS ANGELES 6UILPING AND SAFETY
I e Ime I / I '
DoteApplicant r FOR APPLICANT TO 71COIMPNO
CONNECTION DATA
CER FICATE OF EXEMPTION FROM WORKERS BUILDING 5-2
COMPENSATION INSURANCE ADDRESS SrATtON DEPTH
(This section need not be completed if the work involved by the LOCALITY MANHOLE REFERENCE i PER
WER
Permit is for one hundred dollars ($100) or less I TYPE a CpNKC110N
I certifyThai in the performance of the work for which this NEAREST LENGTH FROM
a per CROs ST Y CURB P L M L TOP L
permit is Issued I shall not employ any parson In any manner LEGAL
so as to become subject to the Workers Compensation LowsP c No
P DESCRIPTION LOT NO LOB NO
Date Apphcant BLOCK TRACT TRUNK PERMIT NO ROAD PERMII NO
NOTICE TO APPLICANT If after Makin this Cerllf icate of ASBESSOR AFFIDAVIT WAVER EASEMENT RECORD INSTR tq DATE
9 MAP BOOK PAGE PARCEL
Exemption you should become subject to the Workers
Compensation provisions of the Labor coda you must forthwith NO OF BLDGS
y 912E OF LOT NOW ON LOT HwY OR Si WIDENING
comply with such provisions or this permit shall be deemed BUILDINGS
OF
eua
revoked DlNas STATE ENcnoAcwvtNl
i LICENSED CONTRACTORS DECLARATION PERMIT NO
I hereby affirm That I am licensed under provisions of Chapter OWNER t
9 (commencing with Section 7000) of Division 3 of The Busi [ADDRESS
ESS CHARGES
ness and Professions Code and my'license Is in full force and
effect TEL NO CONNECTION CHARGE FEE
License Number LI, Class E REIMBURSEMENt FEE
RACTOR
Contractor Dote E� DIBIRKT NO GRWv MAP SSFD BY
D Bx PO 1 am exempt under Sec of the L A Co �TEL NO Pl u mbmg Code and/a,Sc of the LIC FINALSENo D Cuss DATE , Z VALIDATIONo
B & P Code for the following reason DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO /]/) FiNAI 73.t}
Date PUBLIC SEWER /v BY• AA I�WL
SEPTIC TANK SEEPAGE FT OR a
Signature PITS AND OR DRAINHELD in
OWNER BUILDER DECLARATION HOUSE SEWER CONNECTING TO , S ITEM
DISPOSAL SYSTEM
I hereby affirm that I am exempt from the Contractor s License CONNECT ADDITIONAL BMG OR
Law for the following reason (Sector, 7031 5 Buisness and Pro WORK TO HOUSE SEWER I1� 73.50
�_ �
fe3Si Or13 Code) �iNFLGW SEEPACrE PIT CESSPOOL DRYWELLL A IMAN` *QT IKKE
ALTER REPAIR DR ABANDON HOUSE
I ei owner of the property Or my employees with wages re SEWER OR DISPOSAL SYSTEM
then sola compensation a,otion wf do the work and the structure CAM
is not Intended or offered for sale (Section 7044 Business Whitt 73.50
and Professions Code)
❑ I as owner of the property am exclusively contracting with OWNER'S Permit s10790 /y�,s��
licensed contractors to construct the project (Section 7044 Owe .00Business and Professions Code) AUTHORIZATION TOTAL FEE , ��
CONSTRUCTION LENDING AGENCY i HAVE At THIS DATE A CONTRACT WITH THE HEREIN NAME CONTRACTOR TO ,
I hereby offam that there IS a construction lending agency CONNECT THE ABOVE DESCRIBED EHSTiNG DWELLING TO THE PUBLIC SEWER EEEsrys_IyEEE1 �O,q?/per
for the performance of the work for which this permit is IA.00-0001 LJ 'J
issued (Sec 3097 Civ C ) SIGNED THIS—DAY DAY OF 19_ ripCp /FP
OWNER OR 2M
39
Lender s Name OWNERS AGENT
s Lander 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
ordnwnces and State laws regulating Plumbing and Sewers
and hereby authorize representatives of this County to enter
upon the above menti ed property for m�c)i^ purpose/ s i
Signature of Permittee Dat �/✓/— It4O/ SEE REVERSE FOR EXPLANATORY LANGUAGE