HomeMy Public PortalAbout5321 WELLAND AVE_Sewer__ WORKERS' COMPENSATION DECLARATION
I ,f e lfby affirm that I hove a certificate of consent to self 20-005I DPW 6/89
ora certificate of Workers' Compensation Insurance, or 76A652D
certified f1rTe f (sec. 3800, Lq"., _.—r — APPLICATION FOR PERMIT
Policy � 3CC pany
certifieday is hereby f,,,n,shPd - SEWER - SEWAGE DISPOSAL
Cert,fied copy is filed with the county building.,vWection / COUNTY OF LOS ANGELES BUILDING AND SAFETY
,� r�
Dates __ � Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
19iRT PATE OF EXEMPTION FROM WORKERS BUILDING
COMPENSATION INSURANCE ADDRESS t _ STAT DEPTH
( P y M,gni
This section need net be completed .f the work involved b the LOCALITY ;O c REFERENCE LOWER UPPER
-
permit Is for one hundred dollars ($100? or less.) l
NEAREST y+ 7'PE OF CONNECTION LENGTH FROM.
I certify that in the performance of the work for which this CROSS S1, 3a —2p:: Y CURB P1 M L TO Pt
permit is issued, I shall not employ any person in any manner LEGAL. PC NO
so as to become subject to the Workers' Compensation Lows. DESCRIPTION LOTNO. CO MP NO J06 NO
BLOCK TRACT TRUNtPERMIT NO ROAD PERMIT NO
Date Applicant_
NOTICE TO APPLICANT: If, after making this Certificate of MAP BOOR nFc DAVIT wAlveR eA,EMEVT RECORD wsrR No DATE
g MAP BOOK PAGE. PARCEL -
Exemption, you should become subject to the Workers' NO.OF BLDGS.
Comeensation provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT
HWY OR ST WIDENING
comply with such provisions or this permit sholl be deemed USE OF
revoked. . BUILDINGS STATE ENCROACHMENT
PERMIT NO
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter OWNER A) PJ1+
9 (commencing with Section 7000) of Division 3 of the Busi- MAIL-
ADDRESS CHARGES
Hess and Professions Code; and my'license is in full force and �J,./ /� �f
effect C!TY TEL NO rj'P Lam+ +��5 CONNECTION CHARGE FEE
License Number W9 0& _Lic. Class CA 4Z ��� REIMBURSEMENT FEE
y CONTRACTOR
Contractor�41& Date_ d 6 -"" ..JJ J DISTR;�i NO GROUP MAP PROCESSED BY
r, ADDRESS "� �R . s�.4e., _.^ �: 4 y Be PG
J 1 am exempt under Sec of the L.A.Co. \' p_
CITY. TEL NO. .�" _ '� 7-
Plumbing Code and/or Sec of the STATE £, ,/ uc F,NAL U
LICENSE No i- Yb L1 5S DATE f A VALIDATION
B. & P. Code for the following reason NO. DESCRIPTION OF WORK FEE ✓ ` 0
He t SE SEWER .ONN, 'INC,To FINAL >-
Date_ PUB ,`SEWER � ..-^7(,,.. By U
J
EP71. TANK SEEPAGE P7 6R CL
Signature PI S ALIJ
4;) )R )PA,NF El'
OWNER-BUILDER DECLARATION HOUSE SEWER ONNECT INC,TO
PRIVATE DISPOSAi,SYS EM Z
I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BDG oR
Law for the following reason (Secton 7031.5, Buisness and Pro- NORK TO HOUSE SEWER
fessions Code)
OVERFLOW SEEPAGE PIT DRAINF-ELD
ExTN CEssnOo, DRvwEL6 MANHOLE
❑ I,a5 owner of the property, or m employees ees with wages as At TER REPAIR OR ABANDON HOI.SE
Y P Y 9- E M
SEV✓.R OR D SPOSA,,SYS'F
their sale compensation,. will do the work and the structure is not intended or offered for sale (Section 7044, Business
and Professions Code?.
❑ I, as owner of the property; am exclusively contracting with
licensed contractors to construct the project (Section 7044. OWNERS Permit $ ��
Business and Professions Code). AUTHORIZATION TOTAL FEE �' .
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CCNIRACT WITH THE HEREIN NAMED CONTRACcc)R TO -
I hereby affirm that there Is a construction lending agency CONNECT THE ABOVE DFSCR�a€D EXISTING DwELL,NG TO THE PUBDr SEVER
for the performance of the work for which this permit Is
issued (Sec. 3097, Civ. C.). SIGNED THIS. DAY OF 'v�
.1W NER<lR
V N
Lender's Name_ ADDRERS AG NT
Lender's Address ___— ADDRESS7.
I certify that 1 have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State lawsr gulat,ng Plumbing and Sewers,
and hereby authorize repr entotives of this County to enter
fu Te above-rnen1,c) property for inspection .,purposes.
Si nature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE