HomeMy Public PortalAbout8715 WENDON ST_Sewer__ WORKERS; COMPENSATION DECLARATION
I, hereby dfilrm that I have a certificate of consent to self 20-005142 DPW BT83
insi Te, Oro certificate of Workers' Campensat on Insurance, or 76A6426
relied ca y tf e{eaf?Sec. 38(70, Lib , _ fJ� APPLICATION FOR PERMIT
Polir"y. No ,l _�4 mpany-_.__� _44_-_---L1-e'' -.
[�,Certtfi€d copy is hereby furnished. SEWER - SEWAGE DISPOSAL
[,-,If Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
deportment
Date- I ;`_A hcanr FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFIIEATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ADORE ss lo, X" STATION DEPTH
(This section need riot be ccmpleied if the work Involved by the v, M,ANHOtE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY f 1 ` "' / J S LOWER
NEAREf certify that in the performance of the work for which this CROSSS1s7,,f y TYPE PE OF CONNECTION LENGTH FROM
CURB PL ML ToPL
permit is issued. I sholl not employ any person in any manner LEGAL
PC NO
so as to become subject to the Workers'Compensation Laws. DESCHIPTION LOT NO CO IMP NO JOB NO
Date--Applicant BLOCK TRACT- TRUNK PERM.iT NO ROAD PERMIT NO
ASSESSOR I AFCIDAVIT WAIVER EASEMFNT RECORD INSTR NO DATE
NOTICE TO APPLICANT: If; after making 'his Certificate of MAPEtoOK n PAGE ePt- PAROEL ���'
Exemption, you should become s�:blect to the Workers' No.OF BLDGS,
Compensation provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON L.01 HWY OR ST WIDENING
comply with such provisions or this permit shall be deemed USE OF
revoked. BUILDINGS STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATIONI PERMIT NO
R r♦ n -� �'
I hereby affirrn that I am licensed under provisions of Chapter OWNE
9 (commencing with Section 7000) of Division 3 of the Bust- MAIL �-
ness and Professions Code, and my'license is in full force and ADDRESS, cwARGEs
effect, i'- J, } x,� J ' CONNECTION CHARGE FEE
"5`- CITY TEL.NO. .J".A-�'`-, 1'I'I
License Number z'� 'h t Lic Class_ 1 REIMS _ EMUJ FEE
.x- CONTRACTOR
r7- s ,t DI _ GROUP .MAP PROCESSED BY
Contractor _ G k jc l date /
ADDRESS ' BK PCS
I am exempt under Sec, of the L.A. Co �g
CITY TEL.NO. ^i / 'L. iC-�.f" 'rY"� O
0
Plumbing Code and/or Sec. of the STATE Ltc, NAI
LICENSE NO CLASS DATE VALIDATION
B. & P. Code for the following reason NDESCRIPTIONOF WORK FEE ( Z
O.
O
SEWER C7NNEC'iNG'L:
Date PUBU�$EWER BY f
SEPTIC TANK SEEPAGE PIT OR d
Signature. AND O6 TRA NFIFLD
OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING TO
PP VATE DI POSH SYSTEM , z
I hereby affirm that I am exempt from rhe Contractor's license ONNECT ADDITIONAL BLDG OR
Law for the following reason (Sectors 7031.5, Buisness and Pro- WOR, TO Ho,jsE SEWER
OVERFLOW SEEPAGE PIT DRAINFIFLD
fr�e--sttSiOnS Cade): EXTN CESSP(?OL DRYWELL. MANNOiE
t_J 1,.as owner of the property, or my employees with wages as ALTER.REPAIR OR ABANDON HOUSE -
their sole eo.mpensoSEWER OR DISPOSAL SYSTEM,will d°the work and the structure --'
is not ntended or offered for sale (Section 7044, Business
and Professions Code).
1, as owner of the property. am exclusively contracting with OWNER'S Permit $ _
licensed contractors to construct the project (Section 7044,
Business and Professions Code), AUTHORIZATION TOTAL FEE ' ,j
CONSTRUCTION LENDING AGENCY HAVE AT THIS DATE A CONTRACT w Tri THE HEREIN NAME 0Wk1ArTOR Tc
I hereby affirrn that there is a construction lending agency CONNECT IHE ABOVE UESCR;SED I XITING DWtELLING TO THE PUB C SEWER
for the performance of the work for which this permit is Poo
issued (Sec. 3097, Civ, C ). SIGNED THIS DAv OF 19,
C)WNER OR _
Lender's Name_ _- O'ANERS AGENT,
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 laws regulating P!vmbing and Sewers,
and hereby t.hori7e represertot ves of this County to enter
Upon the a ave-nentianedparty for Irspe tion purposes
It 51
SPgnature of IsT Date SEE REVERSE FOR EXPLANATORY LANGUAGE
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