HomeMy Public PortalAbout4815 ALESSANDRO AVE_Sewer__ S � i
WORKERS COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self "
Insure or a certificate of Workers Compensation Insurance or 76A642D
a certified copy thereof (Sec 3800 Lab C > CE 808(REV 8/8I) APPLICATION FOR PERMIT
Policy No Company O: o
❑ Certified copy is hereby furnished SEWER - SEWAGE DISPOSAL
❑ Certified copy Is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
dept
art en
Date Applicant T FOR APPLICANT TO FILL IN CONNECTION DATA
ERTIFICATE OF EXEMPTION FROM WORKERS BUILDING STATION DEPTH
COMPENSATION INSURANCE ADDRE
(This section need not be completed If the work Involved by the MANHOLE REFERENCE UPPER
permit Is for one hundred dollars ($100)or less ) LOCALITY LOWER
NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that In the performance of the work for which this CROSS ST Y CURBP L ML TO P L >'
permit Is Issued I shall not employ any person In any manner d
OWNER CO IMP
so as to become subject to the Workers Compensation Laws NO JOB NO c No O
j �
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PP —•� / MAIL V
Date A licant � C� ADDRESS L TRUNK PERMIT NO ROAD PERMIT NOat
NOTICE APPLICANT If a{ter making this Certificate of CIT AFFIDAVIT WAVER EASEMENT RECORD INSTR NO DATE 0
Exemption you should become subject to the Workers �� TEL NO
Com ensation provisions of the Labor code you must forthwith GAL W
P P Y DESCRIPTION LOT NO HWY OR$T WIDENING d
comply with such provisions or this permit shall be deemed N
revoked BLOCK TRACT STATE ENCROACHMENT z
—
LICENSED CONTRACTORS DECLARATION NO OF BLDGS PERMIT NOSIZE OF LOT Now ON Lor
I hereby affirm that I am licensed under provisions of Chapter USE of
9 (commencing with Section 7000) of Division 3 of the Busl BUILDINGS CHARGES
ness and Professions Code and my license is In full force and
effectCONTRACTOR l CONNECTION CHARGE FEE
License Number +++���"Af- LL-LIC Class ADDRESS ! REIMBURSEMENT FEE
, DISTRICT GROUP MAP PR ESSED BY
Contractor to / CITY 7' L, TEL NO BK PG
TA❑ I am exempt under Sec of the L A Co LICENSE NO LIC
'L
Plumbing Code and/or Sec of the NO DESCRIPTION OF WORK FEE FINAL
HOUSE SEWER CONNECTING TO DATE ��� ® p > VALIDATION
B & P Code for the following reason PUBLIC SEWERSEPTIC TANK SEEPAGE PIT OR 3
PITS AND/OR DRAICONNECTING
FINAL
� HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG OR �/ ►
NER BUILDER DECLARATION WORK TO HOUSE SEWER
I hereby affirm that I am exempt from the Contractors License
OVERFLOW
TNFLCESSEPOOL DRYWELLGE PIT MANHOLE x
Law for the following reason (Secton 7031 5 Buisness and Pro ALTER REPAIR OR ABANDON HOUSE z 2 1 6 6 A
fessions Code) SEWER OR DISPOSAL SYSTEM
❑ I as owner of the property or my employees with wages as # ° ° ° ° 1 0
their sole compensation will do the work and the structure
Is not intended or offered for sale (Section 7044 Business r 21° 02-1 50
and Professions Code) OWNERS Permit $ c
❑ I as owner of the property am exclusively contracting with AUTHORIZATION TOTAL FEE ° ° ° 2 1 5 0 c=i
licensed contractors to construct the project (Section 7044 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONT ACTO TO
Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER 0523-83
CONSTRUCTION LENDING AGENCY ►
I hereby affirm that there Is a construction lending agency SIGNED THIS AY 19_
for the performance of the work for which this permit Is OWNER OR
OWNERS AGE T
Issued (Sec 3097 Civ C )
ADDRESS r
Lender s Name
Lender s Address
I certify that I have read this application and state that the
above information Is correc I agree to comply with all County
ordin c d State I S gulating Plumbing and Sewers a
an er y auth ze epr sentatives of this County to enter
U n t ov n on property for Inspect) wo
Ignature of P mitiee Date SEE REVERSE FOR EXPLANATORY LANGUAGE