HomeMy Public PortalAbout9619 WOODRUFF AVE_Sewer__ WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a cer?(ficate of consent to self 20 0051 DPW&89
insure, or a certificate of Workers' Compensation Insurance, cir 76A642F)
a certit,ed copy thereof (Sec. 3800, tab C, APPLICATION FOR PERMIT
Policy No -Company--
[-- '
J 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
Date Applicant FOR APPLICANT TO 1711 IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' STA-;CN DEPTH
COMPENSATION INSURANCE A 111)1-11�2 !&/q I,,-/
(This section need not be completed if the work !nvoived by the MANHOLE PEUQ�N,E
permit is for one hundred dollars ($100)or less.) �OCAUTY e LOWER
or which this IF='SSS�- TYPE,OF CONNECT�O.',4
I certify that in the performance of the work far NEA fNG7H FROM
J-�;4 1//-) Y CURB P %,'. TO P1,
permit is issued, I shall not employ any person in any manner EGAL P C hiO
FA 'D
D R-3
OCA'I,Y
IA�'
,E- AL
so a-, to become subject to the Workers' Compensation Laws IDES�C-RIPTION LOT NO CO IMP NO jDfl NC
D
Date--...... Applican! BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
AFFIDAVIT WA,VER EASEMENT RECORD !NSTR NO DATE
I"P
a , o I PARCEL K, 4-
NOTICE TO APPLICANT, If, after making this Certificate of: MAP 0`1 ZY
Exemption
on, you should become subject to the Workers' 'AGE
NO OF 811 Dos
Compen on provislons at the Labor code, you must forthwith I Z,E NOW ON,-c; HWY OR ST N-DfNiNG
comply •vi!h such provisions or this permit shall be deemed LISE 0'1 DACHMENT
,evoked. PUIUDINCS AI STATE ENCR(
LICENSED CONTRACTORS DECLARATION PERM;T NO
1 hereby affirm that I am licensed under provisions of Chapter OL'VNER
9 (commencing with Section 7000) of Division 3 of the Bu%i MAIL
ADDRESS CHARCES
ness and Professions Code, and ml license Is in full force and
CONNECT;ON;HARCE FEE
effect CITY TEL.
License Number-Lic, ClassJ-
Contractor CONTRACTOR "d X ii, Di5TR,Cl NO CAOUPMAP PROCESSED BY
BV FG❑ cli�
I am exempt tinder Sec.---of the L-A. Co, if
CITY TEL.NO CL
Plumbing Code and/or Sec, of the ST.,TE cINA, 0
UCENSP NO CLASS DATE VALIDATION z
B. & P Code for the following reason NO- DESCRIPTION OF WORK FEE 2
HC>E SEWEre
NAi, Ir-
Dote P
y 0
SE PT" ,ANK- SEEPAGE PIT'CA
Signature T$Arab 0 JR DRANFIFID CIL
"
C0
OWNER BUILDER DECLARATION N0,SE SEWER CONNECN(3 TO
PRIVATE DISPOSAI,SYSli z
I hereby affirm that I am exempt from the Contractor's License (.ONNECT ADI' OU 5,DG c)R ILI'
Low for the following reason (Secton 70311,5. Buisness and Pro- NORK TO HC-SE-EWER
fessions Code): VERFLOW SEEPACE PIT DPAINEIELD
[�TN CESSPOO, DRYWELL MANHOLE
E 1, (is owner of the property, or my employees with wanes as ALTIR REPAIR CA AB4NDON ICu5F
3303 15
SEWER OR DISPOSAL SYSTEM
their sole compensation, will do the work and the structure
s not Intended or offered for sale (Section 7044, Business
I ITEMS
and Professions Code". TOT& 53 -70
1, as owner of the property, am exclusively contracting with
licensed contractors to construe' the protect (Section 7044 OWNER'S Permit $ 53.70
Business and Professions Code). AUTHORIZATION TOTAL FEE
CONSTRUCTION LENDING AGENCY .00
HAVl AT .HIS HATE A t-ONTRACIT ATH 'HE ieERIFIN '11r0fD fCJ
I hereby affirm that there is a construction lending agency :ONNE(T THE ABC',f.r.A5(7P1PTD EXiST,NC,DWEL)IING YO THE PU6,1( SEWER
for the performance of the work for which this permit o: SIGNED THIS_DAY OF 19 115
issued ('Sec 3097, Civ. C.) 5/95
CA"N FR OR 12 11:34
Lender's O'NiNFRS AGEN' P,
Lender's Address--,
I certify that I have read this oppljcot,on and state tkat the
above information is correct. I agree to comply
with all crjun,y
ordinances and State lows regulating Plumbing and Sewers,
and h,,eceby.,,dvthorize,representolives of this County 2o enter
upon`0-,6,o�G-4-meAi�n pr p.er,!.y for insp ct,on D rposes
Si4natur(4Of Perm; tee Date SEE REVERSE FOR EXPLANATORY LANGUAGE