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Home My Public Portal About5256 SERENO DR_Sewer__ WORKERS COMPENSATION DECLARATION 1 hereby affVm that I have a cemficale of consent to self 70.W51 DPW W89 msuse Or a certificate of Workers Compensation Insurance or 76A6420 a certified copy thereof (Sec 3800 Lob C , 1 APPLICATION FOR PERMIT Policy No Compgpy ❑ Certified copy is hereby furnished SEWER -,SEWAGE DISPOSAL. - ❑ Certified copy Is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING ND SAFETY department Dote Apphcont - FOR APPLICANT TO FILL IN _ CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE• AUDOAESR R STATION DEPTH (This section need not be completed if the work Involved,by the LOCALITY MANHOLE REFERENCE LOWR UPPER permit a for one hundred dollars ($100)or less ) - rrrvE of coNNfrnaN IENGrH FROM certify that m the performance of the work for which this NEAREST CROSS ST v CURB PI MI-TO Pt permit Is Issued I shall not employ any penon In any manner so as to become subject to the Workers Compensation Laws DEB AIPTION LOT NOCo IMP No + titi c NO F Dale Applicant BLOCK iPACT19UNx PERMii NO ROAD eE4.WT tip NOTICE 10 APPLICANT If after making this Certificate Of �FppEgapN Q�J PAGE /� PARCEe"o MFlDAVIT WAIVER EA56y[NT RECORD IrSi4 NO PATE Exemption you should become subject to the Workers FED OF BLOT t Compensation provisions of the labor code you must forthwith s of LOT Now ON LOT Hvry MST WIDEN1iVG comply with such provisions or this permit shall be deemed uREOF revoked euILOINas STATE ENCROACHMENT PERMIT NO LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter OWNER 9 (commencing with Section 7000) of Division 3 of the Busl "IL I_/�'" O+ARGfs messADORERS v v 'I effect and Professions Coda and my license Is In full force and Y �� effect , fJTY TEL NO CONNECTION CHARGE FEf License Number Lc Class 4EiMBUR%&AEm FEE CANTRACTOR Contractor Date DISTRICT ND GROl1P AUP PgOCFSSED er ADDRESS ea Pc ? ❑ I oat exempt under Sec of the L A Co r a� , �� 1 Cltt TEL NO Plumbing Code and/or Sec ofthe STATE LIC FINAL bqVVALIDATION LICENSE NO CLASS DATE Z B B P Code for the following reason NO DESCRIPTION OF WORK FEE O a HOUSE SEWER CONNECIIN(TO FINAL F Date Putc SfwE4 By (� 1 SEPTIC TANK SEEPAGE PIT OR W .Signature PITS AND OR GRAINFIELD 0. WUSf SEWER COK IING TO N OWNER BUILDER DECLARATION "NATE O15Fo5A sr M , i Z I hereby affirm that I am exempt from the Contractor s License WORKTO ODi sONAAL DG OR 1[I Law for the following reason (Secton 7031 5 Buisness and Pro fessions Code) OVERFLOW SEEPAGE til GRAINFIELD ExTN CESSeOOL MyWELI MANHOLE �{� 1 Al TER RE PAIR O4 ABANDON HOUSE 111•L T.Tf ❑ I their owner of the property or my employees with wages re SEWER pt D15POSAI SYSTEM •}'7i� thea sole compensotlon will do the work and the structure ,Aj 6g.3 I Is not Intended or offered for sale (Section 7044 Business 1 ITEM and Professions Code) ITEM i.] �I as owner of the property am exclusively contracting wnh OWNER'S Permit S TOTAL 69 . 30licensed contractors to construct the project (Section 7044 Business and Professions Code) AUTHORIZATION TOTAL FEE CHECK 69.,13 CONSTRUCTION LENDING AGENCY 1 HAVE AT THIS DATE A CONTRACT WITH INE HEREIN NAMED con RACtOR TO , '" � � ` , ,�@ I hereby affirm that there Is a construction lending agency CONNECT THE ABOVE NKRIB1 G TNG Divfikl TO THF PueuC SEWER for the performance of the work for which this permit is issued j issued (Sec 3097 CIv C ) SIGNED TM15 of 19Lrl W • ' ��i� �E'E�'�E 6 OWNEP OR OOOO�IJtJ I 6/29/'-0 Lender s Nome OwNE45 AGENT Lenders Address ADDRESS OL522 . 1 API1:2zF 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 laws regulating Plumbing and Sewers an�t hereby authorize representatives of this County to enter zaz�xo perty for mspectio purpos t9#b tfreof Permivee Dote SEE REVERSE FOR EXPLANATORY LANGUAGE