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Home My Public Portal About5252 SERENO DR_Sewer__ WORKERS COMPENSATION DECLARATION ` jT I hereby affirm that I hove a certificate of consent to self 70 OD51 DPW BBB U insurer oro certificate of Workers Compensation Insurance or 7SA642D Policy copy thereof (Sec icyLab C , 1 Policy No Compannyy -APPLICATION FOR PERMIT It • ❑ Certified copy is hereby furnished 1 SEWER -,SEWAGE DISPOSAL I ❑ Certified copy Is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAF,RTY deportment Dote Applicant FOR APPLICANT TO FILL IN CONNECTION DATA • CERTIFICATE OF EXEMPTION FROM WORKERS BUILOWG COMPENSATION INSURANCE ADpf1E55 STATION DEPTH (This section need not be completed,f the work Involved by theMANHOLE REFERENCE -UPPER ,permit ,s for one hundred dollars (S100)or less J LOCALITY L R certify that-intheperformance of the work for which this NEAAEST - - TYPE OF CONNECTION LENGTH FROM CROSS 9T r CURB P 1 Mk TO F L permit Is issued I shall not employ any person ,n any manner so as to become subject to the Workers Compensation Laws LEGAL DESCRIPTION LOT NO C NO Co[O IMP NO JOS NO Dole Applicant BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO NOTICE TO APPLICANT If after makingthis Certificate of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSL4 NO DATE MAP BOOK ��,! Q O PAGE Exemption you should become subject to the Workers NO OFON LOGS Compensation chYpro is of the Labor coda you must forthwith 512E OF LOT NOW ory LOT MVr MST W,DN,NG comply with such provisions or this permit shall be deemed USE OF revoked BUILDNGS STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION / PERMIT NO I hereby ofbrm that I am licensed under provisions of Chapter OWNER L 9 (commencing with Section 7000) of Division 3 of the Bus, MAIL nese and Professions Code and my license ,s ,n full force and ADDRESSCHARGES effect . CITY J TEL NO 7CONNECTION CHARGE FEE License Number Lic Clam I REIMBURSEMENT FEE CONTRACTOR Contractor Dote DISTRICT NO GROUP MAP PROCESSED BY ADDRESS 9x PG ❑ I am exempt under Sec of the L A Co I - CITY TEL NO i Plumbing Code and/or Sec of the STATE LIC FINAL LICENSE NO GLASS DATE VALIDATION Z B 8 P Code for the following reason No DESCRIPTION OF WORK FEE 0 Date HOUE SEWERPUBLIC SEWER CDNNFCi,NG 10 �BIy F U • SEPTIC TANA SEEPAGE PITOR W Signature PITS AND ORDPAINfIFLOIO a OWNER BUILDER DECLARATION HOUSE SEWER CONNECTING TO ► Z PRIVATE DISPOSAL SYSTEM I hereby off um that I am exempt from the Contractor s License - CONNECT ADDITIONAL BLDG OR 1� Law for The following reason (Section 7031 5 Bunness and Pro 11 WORK TO H SEWER fessions Code) OV1RROW SEEPAGE PIT DRAINFIELD CT.T EXTN CESSFWAC L DRYWELL MANHOLE Fib ❑ 1 as owner of the ptoperty or my employees with wages osALTER REPAIR OR ABANDON HOUSE '{ LC.`j their sole compensation will do the work and the structure . SEWER OR DISPOSAL SYSTEM y V`I'IJ� C'] is not intended or offered for sale (Section 7044 Business - 1 ITEMS d Professions Code) R__0s owner of the property am exclusively contracting with TOTAL 69 - 30 licensed contractors to construct the project (Section 7044 OWNER'S Permit S Business and Professions Code) AUTHORIZATION TOTAL FEE CHECK 69.3D CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON RA[rORO Pilo .00 I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DAYLONG TO THE PUBUC SEWER for the performance of the work for which this permit is ` ' issued (Sec 3097 Civ C ) SIGNED THIS 9 ��F�p� FtF1F� n-, s Lender s Name '- O"NER OR LR.`tJl!-14!01 6/29/`l. OWNERS AGENT Lender s Address ADDRESS 0521 1 AM 12:24 1 certify that I have read this application and slate that the above informotan is correct I agree to comply with all County ' - ordinances and State laws regulating Plumbing and Sewers and here i aulhonze repro entatives of this County ro time. _ Apo a ave nho ed roperty for inspection put oses ' � s e o rm,l Data SEE REVERSE FOR EXPLANATORY LANGUAGE