HomeMy Public PortalAbout5327 WELLAND AVE_Sewer__ . , WORKERS' COMPENSATION DECLARATION 20-0051 DPW 6/89
I. ":ereby affirm that I have a certificate of consent to self 11��11
insure, or a certificate of Workers' Compensation Insurance, or 6A6n2U
a certified copy thereof ,sec 3800, Lab C ) APPLICATION FOR PERMIT
.Policy;No
C,
ympany � � "�_
�; �eert,�f,ed'co p 'sshhe here furnished. - SEWER - SEWAGE DISPOSAL
❑ Certified copy is filed with the county building nspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department ') i
Date 2 , Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS BUILDING
COMPENSATION INSURANCE ADDRESS ,J= r}rf STATIC DEPTH
(This section need not be completed if the work involved by the -^ ' P ANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY a }� LOWER
NEAREST ,/" `YPf OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. rnn E TOP L
permit is issued, I shall not employ any person In any manner ' ' CURB P L
LEGAL PC NO
so as to become subject to the Workers' Compensation Laws. DESCRIPTION LOT NO, CO IMP NO JOB No
Dote Applicant BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
NOTICE TO APPLICANT: If, after makinghis Cerificote of ASSESSOR AFF DAVIT wAIVIII EASEMENT RECORD wSTR NO r,ATE
MAPBOOK PAGE PARCEL
Exemption, you should become subject to the Workers' No.OF BLDGS.
Compensation provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT
comply with such provisions or this permit shall be deemed USE OF Hvr: RAST wlDevwc
revoked. BUILDINGS STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION PERMIT NO
I hereby affirm that I am licensed under provisions of Chapter OWNER
9 (commencing with Section 7000; of Division 3 of the Busi- MAIL ' CHARGES
Hess and Professions Code, and m)r license is in full force and ADDRESS
effect, ,r` (p.�' rte`+ qty/ GiTtig�CL TEL NO CONNECTION CHARGE FEE
License Number T CIT Y Llc.Class l -L P � CONTRACTOR REIMBURSEMENT FEE
''��"'/
COntroctor btLa —Date-7— // 2^y DISTRICT NO GROUP MAP PROCESSFD BY
ADDRESS lr? !r ,/0 !L�'� � � 3K PG
I am exempt under Sec. __of rhe!..A Co. y'] .y,y C� /�
CIT`{ -.U �1f l'+4�+'� TEL.NO,,,a., 3yr�v `
Plumbing Code and/or Sec. of rhe STATE LIC. F,NAL e_ 0
LICENSE NO. 6 CLASS DATE VALIDATION
B. & P. Code for the following reason No. DESCRIPTION OF WORK FEE 2 ?G O
ll HOiJSE SEWER:ONNECIING TOJ FINAL
Qate_ �.^ 1 PUBLIC SEWER 4. 1 BYC.�
SEPTIC TANK SEEPAGE PIT OR W
4��- CL
Signature ITS ArdD OR L'RAINF'EtD U)
TOUSLE SEVER CONNECTING TO
OWNER-BUILDER DECLARATION PRIVATE DISPOSAL SYSTEM ® Z
I hereby affirm that I am exempt from the Contractor's License CONNECT ADD-IONAL BLDG OR
Law for the following reason (Secton 7031.5, Buisness and Pro- I WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT DR
AfNFIELD
fessians Code)- EXTN.CESSPOOL DRYWELI MANHOLE
❑ I, as owner of the property, or my employSEWER OR D,SPC)SAL SYSTEMees with wages as ATo'.
TER REPAIR OR ABANDON H ,_S.E
their sole compensation, will do the wank and the structure. -
is not intended or offered for sole (Section 7044, Business
and Professions Code),
I, as owner of the property, am exCluslvely contracting with Permit $ a
licensed contractors to construct the project (Section 7044, OWNERS
Business and Professions Code). AUTHORIZATION TOTAL FEE 55
CONSTRUCTION LENDING AGENCY i HAVE AT THIS ,ATE A CONTRACT w TH THE HEREIN NAMED CONTRACTOR TO ►
I hereby affirm that there ,5 a construction lending agency CONNECT THE ABOVE DE5CRIBED EXISTW,64VELLING TO Ty1E PUB �_SEWER -
for the performance of the work foF which this permit Is y4 r
issued (Sec. 3097, Civ. C.). SIGNED THIS.,��! �' DAY Q ly
OR•
Lender'sowNEaS AGENT
Lender's Address — ----- 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 laws regulnt,n Plumbing and Sewers,
and authorize representati- s of this County to enter
upon the ab ve mentioned prop y far inspection purposes.
n
_/t naF �- .,
Sigtu of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE