HomeMy Public PortalAbout5235 SERENO DR_Sewer__ r
WORKERS COMPENSATION DECLARATION {�
I hereby affirm that I have a certificate of consent to self 201X1511 DM&89 U
' Insure or o certificate of Workers Compensation Insurance or IBABA2D
o lacy led copy thereof (Sec ny Lab ) APPLICATION FOR PERMIT
Policy No company SEWER - SEWAGE DISPOSAL
ElCertifiedcopy Is hereby faro lshad
(�Certified copy is filed with the county building i spection COUNTY OF LOS ANGELES BUILDING AND SAFETY
Ell men,
Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CE T ICATE OF EXEMPTION FROM WORKERS BUILDING -
COMPENSATION INSURANCE ADDRESS STATION DEPTH
(This section need not be Completed If the work Involved by the LOCALITY REFERENCE UPPER
4
permit Is for one hundred dollars ($700) or less )
certify ilial In the NEAREST - TYPE OF CONNECTION IENGIH FROM
y performance of the work for which this CR08SST / Y CURB RL ML TOPL
permit Is Issued I shall not employ any person In any manner LEGAL
so as to become subject to the Workers Compensation Laws DESCRIPTION LOT NO P C NO
CO IMP tip LOB NO
Date Applicant j WK
K TRACE TRUNK PERMIT NO - ROAD PERMIT W
NOTICE TO APPLICANT If after makingthis Certificate Of SSOR AFFIDAVIT WAIVED EASEMENT RECORD INSi4 NO DATE
BOON PAGE PARCEL
Exemption you should become subject to the Workers INO OF SLOGS
Compensation provisions of the Labor code you must forthwith l OF LOT NOVON LOT HWY ORS1 WIDENING
comply with such provisions or this permit shall be deemed F
revoked INOS STATE ENCROACFWjM
LICENSED CONTRACTORS DECLARATION PERMIT NO
_ 1 hereby affirm that I am licensed under provisions of Chapter ER
9 (commencing with Section 7000) of Division 3 of the Busl
ness and Professions Code and my license Is In full force and E CHARLES
effect TEL NO CONNECTION CHARGE FEE
License Numbe be Class 41416 TRACTOR RfIMTRICT N ENT FEE
COaroic r Date DISrPICI NO GROUP MAP P4OCESAO BY
p ESS — BX PGI am exem t under Sac of he L A CoEL OPlumbing Code and/or Sec of the E sec LATESE NO / CLASS DATE f VALIDATION Z
B 8 P Code for the following reason No NOF o K FEE
HOUSE SEWER CONNECTING TO FINAL f
Date PUBLIC SEWER By W
41, SEPTIC SEPTIC TANK SEEPAGf PIT OR
G/ Signature PITS AND O4 OR IL H
OWNER BUILDER DECLARATION HOUSE SEWER CONNECTING TO ► Z
PRIVAr ISPOSAI Sy51EM l0
I hereby affirm that I am exempt from the Contractors License CONNECT ADDITIONAL BLDG OR 1
—Low Low for the followinSecton 7031 5-Bwsness and Pro- _ --- WORK TO HOUSE SEWER— __
g reason ( OVERFLOW SEEPAGE PIT GRAINFIELD
fe3NOn3 Cade) EXTN CESSPOOL D4YWELL MANHOLE
❑ I as owner of the property or my employees with wages as AITER REPAIR OR ABANDON HOUSE 3M 73.50
-' their sole compensation well do the work and the structure SEWER OR DISNSAL SYSTEM- ITEMS-
isi
not Intended or offered for sole (Section 7044 Business TOTAL3 .50
and Professions Code)
❑ I as owner t the property am exclusively contracting with OWNER'S Permit $ Q AIE�mmil IM29M
licensed contractors to construct the project (Section 7044 1�7W L110B
Business and Professions Code) AUTHORIZATION TOTAL FEE Q
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAME ONTRACTOR To ► '
I hereby affirm that there is o construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THF W UC SEWER
-.- for the performance of the work for which this permit is -
Issued (Sec 3097 Civ C ) SIGNED THIS DAY OF 19_
ONN P OR
Lender s Nome i OWI 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 Iowa regulating Plumbing and Sewers
and hereby authorize representatives of this County to enter I
upon the above mentioned property for nsp tion rposes
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Signature of Permireer Do T/ v I SEE REVERSE FOR EXPLANATORY LANGUAGE