HomeMy Public PortalAbout5246 SERENO DR_Sewer__ WORKERS COMPENSATION DECLARATION {�
I herepy affirm that 1 have a certificate of consent to self 20 DOST DPW BIBS U
Insure or a certificate of Workers Compensation Insurance or 7BA6I2D
o Policy
led copy therepf (Sec Lab , APPLICATION FOR PERMIT
Polay No Companyny
❑ Certified copy Is hereby furnished SEWER - SEWAGE DISPOSAL
❑ Certified copy is flied with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department
Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS BULDIHG ^ '
COMPENSATION INSURANCE ADDRESS l'� /L
S,A,tON DEPrN
(This section need not be completed If the work involved by the Z MBNHaE REFERENCE UPPER
permit Is for one hundred dollars ($100)or less ) LocAUTr L
1 certify that In the performance of the work for which this NEAREST TYPE Oi CONNECTION UNOTH FROM
CROSS Sr 7Y r CUPS P L M l TO F L
permit Is Issued I shall no, employ any person In any manner LEGAL PC NO
so as to become subject to the Workers Compensation Laws DESCRIPTION LOT NO co iMP No toe NO
eLocN
Date Apphtam TRACT rRIJNs PERWT NO ROAD PERMIT NO
NOTICE TO APPLICANT If after makingthis Certificate of X.1 If
AFFIDAVIT WAIVER EASEM(NT RECORD INSTO NO OAlt
Exemption MAP BOON .1I PAGE D PARCEL
p you should become subject to the Workers
Compensation provisions of the Labor code you must forthwith SIZE OF LOT NOWores OT
Nwv Oe sr WIOFNING
comply with such provisions or this permit shall be deemed LSE OF
revoked BUILDINGS STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION
(_14 PERMn NO
I herebyaffirm that I am licensed under OWNER
provisions f t Chapter
9 ss and(commencing ions Section d70DO)my of nsDivision 3 of the Bust MAIL _ d '/
AOORE65 L/ /Tv CHARGES
ness and Professions Code and my license si m full force and Ay
effect CITY TTT TEL NOf4q CO C""`N CHARGE FEE
License Number Lc Class REIMBURSEMENT FEE
CONTRACTOR 7�/� G ka,
Contractor Dole DISTRICT NOJGP MAP PROCESSED BYADDRESSp Bit y❑ 1 am exempt under Sec of The L A Ca Orr iEL NO rlJp IJJ ,�- a
Plu mbmg Code and/or Sec of the STATE LIC INgL V
LICENSE NO CLASS DATE `A VALIDATION Z
B 8 P Code for the following reason NO OMPILPRDS OF WORK FEE D 0
HOUSE SEWER CCINNECTING 10FINAL
Date PUBLIC SEWER By
S Ii IL'ANc SEEPAGE PT OR r1 W
Signature Pits AND OR MAINFtEID 1V S
OWNER BUILDER DECLARATION HOUSE SEWER C I 'N T,xRG to , ALIT =
tWrvSE E t s ITJN A
I hereby affirm that I am exempt from the Contractors License Ca NECT ADDITIONAL BLDG OR .T
Low for the following reason (Secton 7031 5 Business and Pro WORK.TO HOUSE SEWER
fessions Code) OVERFLOW SEEPAGE PT DPAINFIELD
ExTN CESSPOOL DRYWELL MANHOE BLC
❑ I as owner of,he property or my employees with wages as ALTER REPAIR OR ABANDON HOUSE 1 jT�•1 h
then sole compensation will do the work and the structure SEWER OR DISPOSAL SYSTEM
Is not intended or offered for sale (Section 7044 Business TOTAL 69 - 30
and Professions Code) IHELK 69.70
1 as owner of the property am exclusively contracting with OWNER'S Permit S riL.LL/rr '�
licensed contractors to construct the project (Section 7044 �Elr9Y11G �I
Business and Professions Code) AUTHORIZATION TOTAL FEE
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NANEO CON RAC10Y 10 ,
1 hereby affirm that there IS a construction lending agency CONNEC,,HE ABOVE DESCRIBED Ex$SIING D,Vfui G TO THE PUNK SEWER tyOCtlI��FYrti 6/29/1;--
for the performance of the work for which this permit Is GOO( ���� VV VV
Issued (Sec 3097 CIv C )I polo
THIS tp� 0518 1 Al .7."1 r
(TUNER OR V•r:
Lender s Name OWNERS AGENI
Lender s Address ADDRESS
I certify that I have read this apphcation and state that the
above Information Is correct I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers
and here ulhprize representatives of this County ,O enter
up t a is men ed er for inspection p 1`ores
s !
sire dF Perm," Dote /� SEE REVERSE FOR EXPLANATORY LANGUAGE