HomeMy Public PortalAbout5248 SERENO DR_Sewer__ .WORKERS COMPENSATION DECLARATION a /'
F hereby affirm that I have a certificate of consent to self KWSt Div 6089U
Insure or a cernbcole of Workers Compensation Insurance or 7GA642D
aPolicy
Ncertified copy thereof (Sec ny Lab , APPLICATION FOR PERMIT
Policy No Company
❑ Certified copy is hereby furnished SEWER - SEWAGE DISPOSAL
❑ Certified copy Is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department
Dole Applicant FOR APPLICANT TO FILL IN _ CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS euILI '
COMPENSATION INSURANCE AOpRDESSNG £i �+ SIAI ON DEPTH
(This section need not be completed of the work Involved by The UPPER
Ixrmsl Is for one hundred dollars($100)or leis )
LOCALITY r *ZMANHOLE REFERENCE - L
NEAREST TYPE P CONNECTION EEIVGTH{qOM
rcertifyit i That m the performance of the work for which this T CROSSST ) F Y CURB P L FAIL TOP L
permit Iw Issued f shall not employ any person In any manner LEGALoi?l P G NO
so as to become subject to the Workers Compensation Laws DESCRIPTION LOT NO ' CO IMP NO 106 NO A
F
Dote Applicant BLOCK TRACT TRUNK PERMIT NO r ROAD PERMIT NO
NOTICE TO APPLICANT If after makingthis Certificate of ASSESSOR ��O� AF{IDAVIT WAIvfR EASEMENT RECORD INSTR NG DAR
MAP BOOK C7 PAGE (� PARCEL
Exemption you should become subject to the Workers
NO OFBLO09
comply
s provisions of the Labor code you must forthwith SIZE Of LOT NOW ON LOT HWv a4 ST wipENING
comply with such provisions or this permit shall be deemed USEOF
revoked ..1 BUILDINGS STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION I ' PERMIT NO
I hereby offirm that I am licensed under provisions of Chapter OWNER /T
9 (commencing with Section 7000) of Division 3 of the Buss MAIL
J /V!/( CHAROEi
news and Professions Code and my license n ADDRESS In full force and y _
effect (CITY ` TEL NO CONNECION CHARGE FEE
License Number Lc Class CONTRACTOR REIMBURSEMENT PEE
Contractor Date DISTRICT NO GROIrP MAP PROCESSED BY
ADDRESS BIT TIO
El am exempt under Sec of the L A Cc - _3
CITY TEL NO � �-" as
Plumbing Code and/or Sec of the STATE FINAL 3
LICENSE NO Q A55
DATE ` O A VALIDATION =
B 8 P Coda for the (allowing reason tro DBxRIPnoR OF woaX FEE D""Ti O
HOUSE SEWER Date PUBLIC SEWER CONNECTN6 TO FINAL
F
U
SEPTIC TANK MIRAGE RT OR ♦ LU
Signature PITS AND OR DRAINFIELD r (L
OWNER BUILDER DECLARATION HOUSE SEWER CONNECTING TO , 1� Z
PRIVATE dSPOSAI IY ifM
I hereby affirm IhotJ am exempt from the Contractor s License CA CT ADDnICNAI BEoG OR ACCT.i
Low for the following reason (Sectors 7031 5 Bussness and Pro WGRK TO HO SEWER 69.
feisloni Code) WERFLOW 51EPAOf PIT DRAINNELD .�
IATN CESSPOOL DRYWER AUNHQf
❑ 1 as Owner of ther0 ert Or m employees with wages as ALTER REPAIR OR AANDOHOUSE
p p y y g BSEWER Ce MStbSAL SYSTEM
is
1 ITEI'IJ
their sole compensation well do the work and the structure + -
is not intended ur offered for sale (Section 7044 Business TOTAL 69 - 30
m� and Professions Code)
LL7 I as owner of the property am exclusively contracting with CHEPermit $
�s 69.3-1�t i {
licensed contractors to construct the project Section 7044 OWNER'S
Business and Professions Cada) AUTHORIZATION
TOTAL FEE
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTDR TO
I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DMLUNG TO THE PUBLIC SEWER , W W-lJVU1 �,`❑��,
for the performance of the work for which this permit Is V 7
Issued (Sec 3097 Csv C ) SIGNED THIS DAY of-1 2, 1],!e 19 1
COINER OR
Lender s Name OWNERS 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 Stole laws regulating Plumbing and Sewers
and hereb au Thor a reYe
niotives of this County to enter _ -
Upon ve m sooperty for Inspection purposes I -
/ n uA 15f rn It ree Date SEE REVERSE FOR EXPLANATORY LANGUAGE