HomeMy Public PortalAbout5262 SERENO DR_Sewer__ WORKERS COMPENSATION DECLARATION =O.ppSt DPW 8188 'l l
here<y ofhrm that I hove a certificate of consent to self 2GO05176A6D U
' Irdure� or o,cerNbcotg of Workers Compensation Insurance or
a certified copy thereof (Sec ny Lab , APPLICATION FOR PERMIT
Policy No Company
❑ Certified copy Is hereby furnished SEWER - SEWAGE DISPOSAL -
❑ Certified copy Is filed with the county building inspection COUNTY OF LOS ANGELES BUI1,DING ANDISAFETY
department
Dote Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS BUILDING
COMPENSATION INSURANCE ADDRESS sT^TION OEPLH
(This section need not be completed If the work Involved by the LOCALITY MANIOLE REFfaENCE _ UPPE c
permit Is for one hundred dollars ($100)or less )
I certify ilial In the performance of the work for which this - NEAREST tYrs OF CONNECTION LENGTH FROM
CROSS ST V CURB P L M I TO P L
permll is Issued I shall not employ any person In any manner LEGAL
so as to become subject to the Workers Compensation Laws DESCRIPTIONPC NO
p LOT NO CO IMP NO, - `CJOE NO
Date Applicant BLOCK Q TRACTF TRUNK PERMIT NO - ROAD PERMIT NO
NOTICE TO APPLICANT If after molting this Certificate of ASSESSOR {�� /O /D AFFIDAVIT wAIVFR EASEMENTaEcoRD INSTa NO DATE
9 MAP BOOK o PAGE PARCEL
Exemption you should become subject to the Workers NO OF BLOCS
Compensation provisions of the labor code you must forthwith WE OF LOT NOW ON LOT HWY DR ST WIDENING '
comply with such provisions or this permit shall be deemed WE OF
revoked - BUILDINGS STATE ENCROACHV[NT
LICENSED CONTRACTORS DECLARATION PEaMrt No
I hereby affirm that Ilam licensed under provisions of Chapter OATIER
9 (commencing with Section 7000) of Division 3 of the Busl MAILcHAaGEs
ness and Professions Code and my license Is In full force and ADDRESS
effect GTY TEL NO CONNECTON CHARGE FEE
L¢ense Number LIC Class ' REVEURSEMENL FE
CONTRACTOR
Contractor Date DISTRICT NO GROUP MAP PaoCEssED BY
ADDRESS eK Pc
❑ I am exempt under Sec of the L A Co
GTY TEL NO // ✓
Plumbing Code and/or Sec of the STATEID
LiN41 - VY
ICENSE NO CLASS DATE VALIDATION -L
B 8 P Code for the following reason NO DESGRPTIDN OF WORK FEE p
s HOUSE SEWER CONNECTING t0 FINAL
Dale PUBLIC SEWER BY
SEPTIC TANK SEEPAGE PIT OR ELI
Signature Mrs AND OR DRAINFIELD a
z
OWNER BUILDER DECLARATION 'OUSE SEWER CONNfCtING t0 =
PRIVATE DI fir
I hereby ofhrm that I am exempt from the Contractor s License CONIi ACUnIGNAI BLOG OR LL
Low for the following reason (Secton 7031 5 Buisness and Pro WORK TO HOUSE SEWER
fesslons Code) OVERFLOW SEEPAGE FIT DRAINVELD ' ACCT
ExTN CESSPOOL M
DRYWELL ANHOLE 3
❑ I as owner of the property or my employees with wages as ALTER REPAIR OR ABANDON HWSf
Edi. I
Thal'sole compensationn will OR DISPOSAL SYSTEM .�l do the work and the structure -
Is not Intended or offered for sole (Section 7044 Business 03 1 I L GI II
.L_-yfond Professions Code) _
/lq I as owner of the property am exclusively contracting wirh P@ETIf $ TOT ' 69 - 30
v ,licensed contractors to construct the project (Section 7044 OWNERS _
Business and Professions Code) AUTHORIZATION TOTAL FEE CR���C��`T 59.31,
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONT ACTOa TO Pootfll'Ds']G .01
I hereby affirm that there Is a construction lending agency CONNECT FHE ABOVE DESCRIBED EKISTING DWEDING TO THE PUBLIC SEWER
for the performance of the work for which this permit Is
Issued (Sec 3097 CIv C ) SIGNEDTH15 DAY OFAt 19
Lenders Name - NIR AGENT _ VWV—�1 6/`5�C1
Lender s Address ADDRESSz /Z 01525 1 AM v:.5
1 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 '
and ef uthorize rep sent Ives of this County to enter
up n e me I pro try for mspectio purpose 3
/4 Avir
iris Per ttee Dot / SEE REVERSE FOR EXPLANATORY LANGUAGE