HomeMy Public PortalAbout5258 SERENO DR_Sewer__ WORKERS COMPENSATION DECLARATION 'I I
I hereby.offrm DPW OMrhe, I have o certificate of consent to self yD 20 005t 0051D I U
msuTe or o cernhcore of Workers Compensation Insurance or
a certified copy thereof (Sec 3800 Lab C , APPLICATION FOR PERMIT '
Policy No. Company
❑ Certified copy is hereby furnished SEWER - SEWAGE DISPOSAL
❑ Certified copy is filed with'the county building in'fcecrion COUNTY OF LOS ANGELES _ BUILDIPAG,AND SAFETY
department
Date Applicant FOR APPLICANT T9L FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS BUILDING ��
COMPENSATION INSURANCE ADDRESS STAnON DEPTH
This section need not be completed if the work Involved b the UPPER
( P Y LOCALITY pWJHIXE REFEMNCE L R
permit is far one hundred dollars (ff the
or less ) _ LENGTH FROM '
NEAREST TYPE OF CONNECTION
I certify that m the performance of the work for which this CROSS 5i r CURB v L M L TOP L
permit Is Issued I shall not employ any person in any manner LEGAL PC NO
so as to become subject to the Workers Compensation Laws DESCRIPTION LOT NO CO IN' NO R NO
Date Applicant • BLGCN TTRR�ACT TRUNK PERMIT NO • ROAD RRMII NO
NOTICE TO APPLICANT If after making this Certificate Of ASS SSOK �/ PAGE "O ppgD Q AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
Exemption you should become subject to the Workers
NO OF BLDGS
Compensation provisions of the Lobar code you must forthwith SIZE OF LOT NOW ON LOT HWY OR 5T WIOENING
comply with such provisions or this permit shall be deemed USE OF
revoked ' BUILDINGS STALE ENCROACHMENT
LICENSED am TRACTORS DECLARATION PERWT N D
t/�
I hereby affirm that I am licensed under provisions of Chapter OWNER L
9 (commencing with Section 7000) of Division 3 of the Bus, MAIL
nes:and Professions Code and my license is In full force and ADDRESS CHARGES
effect . i CITU TEL NO lo CONNECTION CHARGE FEE
00 09
License Number LK CTO" 4 REIMBURSEMENT FEE
CONTRACTOR
Contractor Date DISTRICT NO GR P MAP PROCESSED By
ADDRESS RD
❑ I am exempt under Sec of the L A Co SKY
CITv TEL NO ,� /// 7�� oao
Plumbing Code and/or Sec ofthe STATE LIC FINAL VALIDATION U
UCENSE NO CLASS DATE .L
B 8 P Code for the following reason NO DESCRIP'll"OF WORK FEF O
HDUSE SEWER CONNECTING TOFINAL f.
Date NBLIC SEWER' BY (�
SEPTIC TANK SEEPAGE PIT OR Q.
SlgnarUre PITS AND OR GRAINFIELD Q.
OWNER BUILDER DECLARATION HOUSE SEWER CONNLCTINIG TOPrZ
ORNATE DISPOSAL SYSTEM
I hereby affirm that I am exempt from the Contractors License I CONNECT ADDITIONAL BLDG OR
Low fonthe following reason (Sector, 7031 5 Buisness and Pro wORK TO HOLM SEWER 1�
fess,ons Code) OVERFLOW SEEPAGE PN DRAINFIELD ^
fXTN CESSPOOL Dkr ELL MANHIXE
❑ I as owner of the property or my employees with wages as ALTER REPAIR OR ABANDON HOUSE ACCT.
SEWER OR DISPOSAL SYSTEM
their sole compensation will do the work and the Business
IIInot Imended or offered for sale (Section 7044 Buvness -rE-y
Professions Code) I ITEMS
as owner of the property am exclusively contracting with
tensed contractors to Construct the project (Section 7044 OWNER'S Permit f _ TOTAL 69 . 30
Business and professions Code) AUTHORIZATION I TOTAL FEE It,.-'7 GEEK 69.3Ct
CONSTRUCTION LENDING AGENCY , HAVE AT THIS DATE A CIXJTPACT WITH THE HEREIN NAMED CONTRACTOR TO ,
I hereby affirm that there ,s a Construction lending agency CONFACT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER ttR'tl7ER. .CII
or the performance of the work for which this permit ,s
issued(sec 3097 C,v C ) Sl(�N1ED THIS
OWNER OAY b/1rs/�,
OF � ID�
P nr,r�
Lender s Name OWNERS AGENT
Lender:Address
ADDRESS Ae - ?; i All `.6
I certify that I have recd this application and state that the f
above information Is correct I agree to comply with all County
ordinances and ate lows,regulating Plumbing and Sewers
and here y th rize re resentatl)Ies of this County to enter
upon t e b d er fo. rnspalleon wpwes 3
Si 0 Date �J SEE REVEM FOR EXPLANATORY LANGUAGE