HomeMy Public PortalAbout5266 SERENO DR_Sewer__ WORKERS COMPENSATION DECLARATION
hgrebt affirm thief I hove.o cemficme of consent to self ZO 0051 DPW 6M
'Insure or a Certificate of WoCompensation Insurance or
rkers ComnTBP.BEZD
o certified ropy thereof (Sec 3800 Lab , APPLICATION FOR PERMIT
Palley Na company
EJCertifiedcopy Is hereby furnished SEWER - SEWAGE DISPOSAL
❑ Certified ccI filed with the county budding Inspection COUNTY OF LOS ANGELES BUILDING AND,SAFETY
department
Dole 'Applicant FOR APPLICANT TO ILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS BUILCING
COMPENSATION INSURANCE ADDRESSL 0 ATgN DEPTH
(This section need not be completed if the work involved by the LOCALITY iAANHCEE REFERENCE UPPER
R
permit Is for one hundred dollars ($100)or less ) _
NEAREST - "FE OF CONNECTION UIRGTH FROM
I certify That in rhe performance of the work for which this CROSS ST r ry CURB PL F ML T0PL
Permit is issued I shall not employ any person m any manner LEGAL Pc NO
so as to become subject to the Workers Compensation Laws MSCMPTION LOT NO Co IMP NO XM NO
Date Appi,co@t BLOCK TRACT TRUNK PERMIT NO c ROAD PERMIT vo
NOTICE TO APPLICANT If after making this Certificate of ASSESSOR �QX(� Q /v AFFIDAVIT wAlvEa EASEMENT aFCORD INSTa NO DATE
Exemption g MAP BOON OG�JJ PAGE PARCEL
p you should become subject o u Workers NO OF ELMS Y
Compensation provisions of the labor rode you must forthwith SIZE OF LOT NOW ON LOT HWy OR ST WIDENING
comply with such provisions or this permit shall be deemed USE OF
revoked BUILDINGS STATE ENCROACFµ1ENT
LICENSED CONTRACTORS DECLARATION PERMIT No
hereby affirm that I am licensed under provisions of Chapter OWNER
.1 hereby
(commencing with Section 7000) of Division 3 of the Busi MAIL
CHARGES
ness and ProfessionsProfessionsCode and my license Is m full forte and
ADDRESS effect . • CITY TEL NO CONNECTpN CHARGE FEE
Lxense Number LIC Class REIMBURSEMENT FEE
CONTRACTOR
Contractor DOt@DISTRICT NOT GROUP MAP PROCESSED By
ADDRESS .�{ B[ PGT
❑ I am exempt under Sec of the L A Co CITY TEL NO L �� J /t I� Y
a
Plumbing Code and/or Sec of the STATE Uc INAL (�,)
LICENSE NO CLASS DATE VALIDATION Z
8 8 P Code for the following recision NO DESCRIPTION OF WORK FEE O
HJUY SEWER CONNECTING TO FINAL
Date PUBIC SEWER • BYKT4 V
SEFTIC TANK SEEPAGE PIT OIR W
PITS AND OR DRAINFIELD LL
.5lggatUr@ pool
N
HOUSE SEWER CONNECT TNG t0
• OWNER BUILDER DECLARATION PalvnrE DisFosAL sysL =
I hereby affirm that I am exempt from the Contractors License CONNECT ADDHIHOKJS1 Y'AALEISLOG OR ifs
Low for the following reason (Section 7031 5 Business and Pro
fessions Code OVERFLOW SEEPAGE PIT DRAINFIEID aLLT.s
Extry CESSPOOL DRYWELL MANFKKE -
❑ I as owner of the properly or my employees with wages as kUR REPAIR OR ABANDON HOUSE
their sole compensation will do the work and the structure SEWER OR DISPOSAL SYSTEM 3M3
s not Intended or offered for sole (Section 7044 Business 1 ITEii"�
,e�id Professions Code) GE 1,
(� I as owner of the properly am exclusively contracting with OWNER'S Permit f TuTAL1�-y7 �' Q
licensed contractors to construct the protect (Section 7044
Business and Professions Code) AUTHORIZATIONJ TOTAL FEE p HEY 69, I1
CONSTRUCTION LENDING AGENCY i HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONT ACTOR TO poll. DLIIIIjCC .[6l
I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DARLING TO THE PUBLIC SEWER `ER'R`ING 4
for the performance of the work for which this permit is �� �/ q
issued (Sec 3097 Civ C I SIGNED THIS DAY OF 9t/
Lenders Name OWNER O
WNERSAaGENr �•.1/ ������� ` 7T� I����� �/ig'�1
lender s Address ADDRESS V oll EF-26 1 AN 3:25
I certify that I have read this application and state that the
above information Is correct I agree to comply with all County +
ordinance d State lows regulating Plumbing and Sewers
on Qr y o that ze repres0nN 'iv of this County to enter
u Ileo menti ed p OPI� for inspecb n p rposes
not eofI1`Brm,IteL& I Dole SEE REVERSE FOR EXPLANATORY LANGUAGE