HomeMy Public PortalAbout5325 WELLAND AVE_Sewer__ WORKERS' COMPENSATION DECLARATION {]
I hereby affirm that I have a certificate, of consent to self 20-0057 DPW&89 ll
t` ms`ure, or a certificate of Workers'Compensation Insurance, or 76AI
116 certified capy'thereaf (Sec. 3$00, L
Parc Co
) APPLICATION FOR PERMIT
��oJ�nany --�tT -------
Certified copy is here(y furnished. SEWER - SEWAGE DISPOSAL
..� Certified copy is filed with the- ounty building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
c '
department %
Dote — %C Applicant a�,.,_...� �Y
— FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' rBUILDINGS
lNc, STATION DEPTH
COMPENSATION INSURANCE ss '044AIJ4
(This section need not be completed if the work involved by the '> MANF;r)LE REFERENCE UPPER
permit is for one hundred dollars !$1001 or less.) ITY LOWER
F.T TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this 5T. �`�� Y CURB PL MI ToPL
permit is issued, 1 shall not employ any person in any manner GAL. PC NO
so as to become subject to the Workers' Compensation Laws. IPTION LOT NO CO IMP NO oe NO
Date _ Applicant. TRACT TRUNK PER.WT NO. ROAD PERMIT NO
NOTICE TO APPLICANT: If, after makin his Certificate of SOR AFF DAvr WAIVER EASEMFNT RECORD INSTR NO DATE
g OOK PAGE • PARCEL.
€xemption, you should become subject to the Workers' NO of RLUGS
Compensation, provisions of the Labor code, you must forthwith f Lor NOW ON:07 HWY OR ST WIDENING
comply with such provisions or this permit shall be deemed Frevoked. INGS STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION PERMIT NO
1 hereby affirm that I am licensed under provisions of Chapter ovarytR '�
9 (cornmencing with Section 7000) of Division 3 of the Bu si- MAtL
AUURESS "� .fit CHARGES
ness and Professions Code, and mV license is in full force and
effect. � CON'ECTION CHARGE FEE
-
��� �y .�t _ CITY �. TeU_NO.
License Number Lic. Class—C-4t y REIMBURSEMENT FEE
��. � �+rr CONTRACTOR GROUP MAP PRC�t:ESSED BY
�z=-4,Q. 7� „'t�'tlr� DISTRICT NO
Contractor 4 d�Dote i
ADDRE C , - 'a a Bk
❑ I am exempt under Sec of the L.A. Co. 0
CITY . ,dlP TEL No +1
Plumbing Code and/or Sec:. of the STATE LIC FINAL r�
LICENSE NO CLASS DATE VAl DATION Z
B. & P. Code for the following reason NO. 1 DESCRIPTION OF WORK FEE O
HOUSE SEWER CONNECTING TCL FlNPt �.
Date — PUBLIC SEWERBYLU
(J
SEPTIC TANK SEEPAGE PIT OR -4.
Signature L S AND OR DRAINFIELD 0)
CWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING TOoilZ
PR.✓ATE DISPOSAL SYSTEM.
I hereby affirm that I am exempt from the Contractor's License CONNECTADDITIONAL BLDG ')R
Law for the following reason (Secton 7.031.S, Buisness and Pro- WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT. DRA'.NFIFID
fe5510 ns Code}' EXTN CESSPOOL DRYWELL.MANHOIF
❑ I, as owner of thep p ro erty' y g or m employees with wages as ALTER REPAIR OR ABANDON HOUSE their sole compensation, will do the work and the structure SEWER OR D:SPOSAL SYSTEM— -- —
is not intended or offered for sale (Section 7044, Business
and Professions Code)
C) I, as owner of the property, am exclusively contracting with OWNER'S Permit $ L
licensed contractors to Construct the project (Section 7044, a_
Business and Professions Code). AUTHORIZATION TOTAL FEE
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WfTH THE HEREIN NA --ONTRACTOR 70
I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCR BED EXISTING DNFLoNG TO T LH,,:SEWER
for the performance of the work for w1hich this permit is
issued (Sec. 3097, Civ. C.1. SIGNEDTHy$`� DAY 19
Lender's Name _ ov Neas AFjtNT f 2
ADDRESS
Lender's Address --
I 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 lows regal ng Plumbing and Sewers,
and hereby authorize represent Ives of this County to enter
�� ebcrvieaepr`Si natroPer Ittee Date —s— SEE REVERSE FOR EXPLANATORY LANGUAGE