HomeMy Public PortalAbout5260 SERENO DR_Sewer__ WORKERS COMPENSATION DECLARATION 1
hereby'affirm That I have a certificate of consent to self 201MI DPW 898
insure or a certificate of Workers Compensation Insurance or 75AS47D
alacyNcertified copq thereof (Sec , ,
Policy No Companyny APPLICATION FOR PERMIT Lab C
❑ 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 ' -
Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS BUILpING
COMPENSATION INSURANCE ADORE55 STATION DEPTH
(This section need not be completed if the work Involved by the MANHOLE aFFfRfr.Kf UPPER '
permit a for one hundred dollars (9100)or less ) LOGLRY LOWER
I certify that In the performance of the work for which this NEAREST TYPEOFCONNECuON - LENGTH FROM -
permit Is Issued I shall not employ an a+OsGALSST ) cuca v L M L Tp R L i
P Y s person In any manner GAL PC NO
so as to becOme'suble<t to the Workers Compensation Laws DESCRIPTION LOT NO CO IMP IJO tp0 NO
Dale • Applicant BLOCK TRACT TRUNK PERMIT NO ROAD PFRINI NO ..
NOTICE TO APPLICANT If after making this Certificate of A pEgppB PAGE "'25PPARCE�O AFFIDAVIT WMVFR fASEMFNI RECORD INSLR NO DATE
Exemption you should become subject to the Workers
Compensation provisions of the Labor code you must forthwithSIZE OF Lor tNO OF SLOGS
OG
HWY OR ST WIDENING
comply with such provisions or this permit shall be deemed LISEOF
revoked WILDINGS STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION PERMIT No i
I hereby affirm that I am licensed under provisions of Chapter OWNER
9 (commencing with Section 7000) of Division 3 of the Bust MAIL
ness and Professions Code and my license is in full force and PODRE55JA It CHARGES
effect GTY TEL NO G / & (�Z CONNECTIDN CHARGE FEE
Lmense Number LIc Class REIMBURSEMENT FEE
CONTRACTOR
Contractor Date DISTRICT NC) GROUP AUP PROCESSED BY
I IX)RE55 BK PG Y
El am exempt under Sec of the L A Co G �Q
rr TEL No S �� a
r Plumbing Code and/or Sec of the STATE
ENo LIC FINAL U
DATE
VALIDATION z
B B P Cade for the following reason MO OEeCPoPT10N OF WORK FEE 1, lzd-� O
Date HOUSE SSEWER EWER CONNECTING TO BNAL H
U
SEPTIC TANK SEEPAGE NT 00 IEE
Signature NIS AND OR DRAINFIfLD W
OWNER BUILDER DECLARATION ' HOUSE SEWER CONNECTING TO poll 1O =
PNVAT ISDOSA15Y5TFM
I hereby affirm that I am exempt from the Contractors License CONNECT ADOTgNAL BLDG OR , '
Law for the following reason (Secion 7031 5 Bwsness and Pro WORK TO HOUSE SEWER F�1a T.`r
fessions Code) OVERFLOWSEEPAGE PIT DRAwnflD
f XiN CESSPOOL axi MANHOLE
❑ I their
owner of the properly or my employees with wages as
ALTER REPAIR OR ABANDON HOLM 33071 69.:a 1
SEWER OR DISPO$µ$Y51LM
then sole c cled a,otion well do the work and the structure 1 ITEMS
n not intended ar offered for sale (Section 7044 Business ITEMS
69 .30
and Professions Cade) TOTAL
1 as owner of the property am exclusively contracting with
bcensed contractors to construct the project (Section 7044 OWNERS Permit S CHECK 69.1--0
Business and Professions Code) AUTHORIZATION TOTAL FEE ���L,��
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH IHE HEREIN NAMED CONTRACTOiP TO ► CEU'Ult� - ,O I
I hereby of(um that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DMUING TO THE PUBLIC SEWER
for the Performance of the work for.which This permit Is
issued (Sec 3097 Civ C ) F t SIGNED THIS ? "� DAY OF 19� 1 '6/29/'30
OWNER OR
Lender s Name OWNERS AGENT 052,k 1 Ah O--,e
7 �.� I
Lender s Address AWRESS
I certify that I have read this application and state thin the
above information is correct 1 agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers ,
and i onze represenlouv s of this County to enter ` A
upo th bo nil ed pr ertl for Inspection pur ses
Si r of rmnte Date SEE REVERSE FOR EXPLANATORY LANGUAGE ,
A