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Home My Public Portal About9302 SPARKLETT ST_Sewer__ WORKERS'COMPENSATION DECLARATION ,4 here¢y affirm Lyot I have a certificate of consent to "if Insure a'a certilfgate of Workers Compensation Insurance or, a certified copy thereof (Sec ny Lab C , Y ISI 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 BUILDING AND SAFETY department Dow-Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS BUKD@G Ur �f .!'pq T STATION OEM COMPENSATION INSURANCE ADDRESSI► ?i (This section need not be completed if the work involved by the LOGALrtY C MAINHOIE REFERENCE UPPER permit is for one hundred dollars($100)or less ) I certify that in the performance of the work for which this pS�SyT s QTO ay rrvEaFCaNmCTroPL IL TCPL Y Has rL MIL E permit is Issued ID hall not emplo y person in any manner P C NO so as to become subject to the rs Compen Lows OWNER Y,, cey% p Co Iun NO )OB No Dore �L ��A licont A�`DORESs 3 2 S PJ Llfri T ST TRUNS PERAUT NO ROAD PERMIT NO PP NOTICE TO APPLICANT If a making this Certificate of CITY ^ P �+1 TEL NO a 3 AEFIDAviT wuvER EAVAVNr RECORD earn IND DATE Exemption you should a subject to the Workers LEGAI Compensation provisions of th Labor code you must forthwith DEsanmlaN LOT No HWY MST WIDENING comply with such provisions or this permit shall be deemed revoked eLOcx TRACT STATE ENCRGACMMEM LICENSED CONTRACTORS DECLARATION NO O BI PERMIT SIZE OF LOT NOW,ON LOT I hereby affirm that I am licensed under provisions of Chapter USE O 9 (commencing with Section 7000) of Division 3 of the Busi BUILDINGS CHARGES nest and Professions Code and my license is in full face and w ' effect CINTRACTOR /v Cjt CONNECTION CHARGE TEE License Number Llc ClassADDRESS REuneuRSEM[NT TEE Contractor DataCIrr m w DISTRICT NO GROCE D UP AW vsOer ((^^ Y ❑ 1 am exempt under Sec of the L A Co STATE No c`C .Js�Y �3 5 A °a LSE O No DESCRIPTION OF WORK rFEEPoumMng Code and/or Sec of the -HOUSE�R CONNECTING DATE ro DATE VALID 6 A i B 6 P Code for the following reason SEPTIC TANK SEEPAGE FIT AND/OR p1AINFIELD� HN #i• • • • 1 (] Dote NiSHOUSE SEWER CONNECTING TO By PRIVATE Signature CONEQ ADDITIONAL BmG OR I • • 2 1.50 OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER • • I hereby affirm that I am exempt from the Contractors License &ARrhOw'EEPAGE Pa ORAeiF EX CESSPOOL DRYwm MANHaE * 2 1.5 0 Law for the following reason (Secton 7031 5, Buaness and Pro- ALTER REPAIR OR AeAEDON HOUSE a 2 8+8 5 f�e".3ps-Code) SEWER OR DISPOSAL S"ni 0 1!7 1,as owner of the property,or my employees with wages as their sole compensation will do the work and the structure Is not intended or offered for sols (Section 7044 Business and Professions Code) OWNER'S Permit f ❑ 1,as owner of the properly, am exclusively contracting with AUTHORIZATION TOTAL FEE licensed contractors to construct the project (Section 7044 I HAVE AT THIS DATE A CONTRACT WITH ME HERIN NAMED CONT ACTOR i0 Business and Professions Code) CONNECT ME ABOVE DESCRIBED EXISTING DWELLING TO THE FUSUC SEWER CONSTRUCTION LENDING AGENCY ► , I hereby affirm that there a a construction lending agency SIGNED THIS DAV OF 19_ for the performance of the work for which this permit a w^'{R OR Issued(Sec 3097 Civ C ) OWNERS AGENT ADDRESS Lenders Name Lender's Address ' I certify that I have read this application and state that the above information Is correct I ogre@ to comply with all County ordinances and State laws regulating Plumbing and Sewer a reby authorize representatives of this County to enter •above-mD�1Jl d property for inspection purposes ,Y 'L Signolum of Permittee Date SEE 2EVEREE FOR EXPLANATORY LANGUAGE