HomeMy Public PortalAbout5242 SERENO DR_Sewer__ ,
.,� WO$KERS COMPENSATION DECLARATION EO OOSt DPw B/8B
I hereby affirm that I hbve a cerMicote of consent to self s 20 W510
Insure or a certificate of Workers Compensation Insurance or
a certified copy Thereof (Sec 3800 Lab C , APPLICATION FOR PERMIT
POIICy No Company SEWER - SEWAGE DISPOSAL
❑ Certified copy Is hereby furnished
❑ Ce,thed copy is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY '
department -'
Dote Applicant FOR APPLICANT TO FILL IN _ CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS BUILDING
COMPENSATION INSURANCE ApOREse Z .e A sTAT'CI' DEM"
(This section need not be completed it the work Involved by the LOCAUTv MANHOLE REFERENCE i c
permit Is for one hundred dollars (SIDO)or less ) _
I certify that fn CROSS ST C1., P the performance of the work for which this NEAREST TYPE OF CONIfNGTH FROM -
RB L M I TO P T
permit is issued I shall not employony person in any manner LEGAL - PC NO
so as to became subject to the Workers Compensation Laws DESCRIKION LOT NO Co IMn NO IC8 NO
Date ApphCant BLOCK SLSORpTR(A�CT TRUNK PERMIT NO ROAD PERMIT NO
NOTICE TO APPLICANT If offer making this Certificate of M PEBOOK d / PAGE PARCEL AFPIDAVn WANNf
E4 fASfNi RECORD INSiR tip p1TF
Exemption you should became subject To the Workers
Compensation provisions of the Labor code you must forthwithNo OP BLOCS
SIZE OF LOT _ NOW ON LOT HWY ORST'WIDENING
comply with such provisions or this permit shall be deemed ME 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 Busl MAIL L� f aARGES
ness and Professions Code and my license Is in full force and ADDRESS
effect CITY TEL NO l CONNECnON CHARGE FEE
Llicense Numher Llc Class - I Ll REIMBURSEMENT FEE
CONTRACTOR W Lf��
Contractor Dote DISTRICT NO OapOP MAP PROCESSED BY
ADDRESG BK PG
❑ I am exempt under Sec of the L A Co 'ref _? n
CITY T TEL NO d .J oc o
Plumbing Code and/or Sec of the STATE SSC FINAs U
LICENSE NO CLASS DATEL VALIDATION =
a
B 8 P Code for the following reson ND DIESCNIPTION OF WORK FEE O
' .OUSE SEWER CONNECTING TO FINAL F
Date PUBLIC SEWER BY V
' SEPTIC TANK SffPACE%T OR W
PITS AND OR DRAINFIELD S
SignatureN
HOUSE SEWER CONNECTING TO =
OWNER BUILDER DECLARATION PRIVATE DI AI SYST M10
I hereby affirm that I am exempt from the Contractor s License CONNECT ADDITIONAL BLDG OT
Low for the following reason (Secton 7031 5 Buisness and Pro WORK TO HOUSE SEWER A4C�.i
fesslons Code) OVERNOW SEEPAGE%T DRMNRELD _
1 ERTN CESSPOOL MYWELL MANHOLE `303 C L9. 'I
❑ I as owner of the property or my employees with wages as A.TER REPAIR OR ABANDON LOUSE
Their sole compensation VidSEWER OR DISNSAI SYSTEMl do the work and the structure 1 1TEM0
Is not Intended or offered for sole (Section 7044 Business TG1AL69- 30
and Professions Code)
�I as owner of the property am exclusively contracting with OWNER'S Permit S � CYi 69. 1
licensed contractors to construct the project (Section 7044
Business and Professions Code) AUTHORIZATION TOTAL FEE 110
CONSTRUCTION LENDING AGENCY I "AVE AT-THIS DATE A CONTRACT WIT. THE HEREIN NAMED ON RACTOR 10
I hereby affirm that there Is a construction lending agency CONNECT THE ABOVE DFSCRIBED ExIS11NG DWftu NO TO THE PUBLIC AMR
for the performance of the work for which this permit is - [ [I WVL 6/?9/i
issued (Sec 3097 Cry C ) SIGNED/NTS AY OF 19
OWNE
V OR _ 0517 1 Ail I1:2•
Lender s Name =WRs AGENT
Lender IF 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 jaws regulating Plumbing and Sewers .,
and her b a Thor z repr se fotrves of this County to enter I
U pon t e bo mm on
ly for Inspection purposes
Ot?xrelbf Permlaee (�Date I SEE REVERSE FOR EXPLANATORY LANGUAGE