HomeMy Public PortalAbout5250 SERENO DR_Sewer__ WORKERS COMPENSATION DECLARATION
I hereby affirm that I hove a certificate of consent to self 200051 DPW WN
Insure or o certificate of Workers Compensation Insurance or 76A64W
a cdHified copy thereof (Sec 3800 Lab C , ' APPLICATION FOR PERMIT
Policy No CorRpony '
❑ Certified copy Is hereby furnished SEWER - SEWAGE DISPOSAL -
❑ Certified copy is filed with the county budding Inspection COUNTY OF LOS ANGELES BUILDING ANDSAFETY
tr
department �+�'`•
Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
• CERTIFICATE OF EXEMPTION FROM WORKERS BUILDING
COMPENSATION INSURANCE ADDRESS STATION DEPT"
chis section need not be completed if the work Involved b the UPPER r
( p y LOCALITY MANFgLE REFERENCE L R
permit is for one hundred dollars (5ft the
or less ) UNGTH FcoM
NEAREST TYPE OF CONNFCTIpR
certify that m the Pparlormance oft the work for which this GROSS ST r f CURB 'P L M L TO R L
permit is Issued I shall not employ any person in any manner LEGAL
so as to become subject to the Workers Compensation Laws oEscmPrPC NO roN LOT NO CO W NO " 105,,00 -'-
Dote Applicant BLOCK TRACT TRUNA KRAFT No ROAD PERMIT NO
NOTICE TO APPLICANT If after makingthis Certificate of ASSESSOR G� AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
MAP BOOK o NO O GS PARCEL D
Exemption you should become subject to the Workers NO OF eLDos
Compensation provisions of the Labor code you must forthwith WE OF LOT Now ON LOT FFwr OR ST WIDENING
comply with such provisions or this permit shall be deemed USE OF
revoked BUILDINGS STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION A PERMIT No
I hereby affirm that I am licensed under provisions of Chapter OWNER
9 (commencing with Section 7000) of Division 3 of the Busi =L
RESS CHARGES
ness and Professions Code and my license Is in full force and ��JJ
effect • CITY TEL NO (/C CONNECTION CHARGE FEE
License Number LIc Class - REIMBD45EWNT FEE
CONTRACTOR
Contractor Date DISTRICT NO GROUP MAP PROCESSED BY
ADDRESSr' S{Ks,, PG
❑ I am exempt under Sec L of the A Co CITY TEL NO ��! �// /� ra
Plumbing Code and/or Sec ofthe STATE UG FINAL 8
LICENSE NO CLASS DATE VALIDATION
B & P Code for the following reason NO DESCRIPTION OF WORK FEE O
HOUSE SEWER CONNECTING TO FINAL f
Dote PUBLIC SEWER Br O
SEPTIC to SEEPAGE PIT OR a
Slgnoture PITS AND OR DRAINFIELD L.
PRIVATESISP
OWNER BUILDER DECLARATION ` HOUSE sDCONNECTING,
Sy . To , 1� _
I %TM ♦.
I hereby affirm that 1 am exempt from the Contractor s License CONNECT ADDITIONAL BLDG OR
Law for the following reason (Secton 7031 5 Business and Pro 'MORA To HOUSE SEWER - t
fessions Code) OVERFLOW SEEPAGE PIT DRMNFIEID . ,r,,303 CF
EXTN CESSPOOL DRrWELI MANHOLE x.1 � 07.311
❑ I as owner of the property or my employees with wages as ALTER REPAIR OR ABANDON HOUSE
thea sola compensation will do the work and the structure SEWFP OR DISPOSAL SYSTEM 1 ITENE
Is not intended or offered for sale (Section 7044 Business TOTAL 69 . 30
and Professions Code)
I as owner of the property am exclusively contracting with OWNER'S PBrTsf f 6 CHECK b9.GU
III
contractors to construct the proleCt (Section 7044
Business and Professions Code) AUTHORIZATION TOTAL FEE CHANCE .D!1
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED Ca+ RACTOP TO
I hereby affirm that there Is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER
for the performance of the work for which this permit Is i c OI�]O-0001 6/29/51-t
�1:
19
Issued (Sec 3097 Civ C ) SIGNED THIS Y OF /( (,/
NER L1 T r1 AM
LenO.
Name Ow
der s NamNAGENT ADEM xU 1 A11 3:24
Lender s Address 4DDRE55
I certify shot I have read this application and state that the
above Information Is correct I agree to comply with all County
ordinances and State lows regulating Plumbing and Sewers
and hereby authorize representatives of this County to enter
upon04
ve^y/rt//Le/�Itio ed opeTry for inspection purposes + ��
��7 NTu� 17a�/� SEE REVERSE FOR EXPLANATORY LANGUAGE