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HomeMy Public PortalAbout5502 ALESSANDRO AVE_Sewer__ WORKERS' COMPENSATION DECLARATION hereby ffirm that I have a certificate of consent to self 20-005t DPW 6189 j�insure, or certificate of Workers' Compensation Insurance. or 76A642D a -PbIT"ylfl `oa�D�f (Sec b` ' APPLICATION FOR PERMIT Lvl Certified copy s hereby furnished —�—�3 SEWER - SEWAGE DISPOSAL ❑ Certified copy Is filed with the county build in mspectlon COUNTY OF LOS ANGELES BUILDING AND SAFETY department Date�dpplican FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' FADDRESS /� �( ,( t� COMPENSATION INSURANCE V� L��� �i�l l/�(� StATION DEPTHPPER (This section need not be completed If the work involved by the MANHOLE REFERENCE LOWSpermit is for one hundred dollars ($100) or less.) NEAREST 6 owER Certify that in the performance of the work for Which this CROSS sr. � .-P © r T. CL—ty gtvp Y TYPE OF CONNECTION LENGTH FROM cuRe PL ML To P L permit is issued, 1 shall not employ any person in any manner LEGAL PC NO so as to become subject to the Workers' Compensation LOWS. DESCRIPTION LOT NO. CO IMP NO JOB NO BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO Date Applicant NOTICE TO APPLICANT: If, after making this Certificate Of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE g 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 HWY OR ST WIDENING comply with such provisions or this permit shall be deemed USE OF r- T��1� revoked. BUILDINGS ��.Jt VZJ�� STATE ENCROACHMENT PERMIT NO LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter ��� � t.SGL% � 9 (commencing with Section 7000) of Division 3 of the Busi- MAIL �[J—� b� r-��. 1Z(� I✓�,�� �.1 CHARGES ADDRESS ness and Professions Code, and myr license is in full force and f effect 0 ;k, CIT,—r-- 0—� t TEL NO Z 0&5 CONNECTION CHARGE FEE License Number O Lic. Class vJ'�- T � CONTRACTOR O L REIMBURSEMENT FEE� /,' DISTRICT NO GROUP MAP PROCESSED BY Contra CtOr �'�L f% ate ADDRESS BK PG ❑ I am exempt under Sec. of the L.A. Co. /r_{��y/- C,4TEL J(((��,/}^� y��// Y p CITY r vb►'_.'"(E, Vy TEL.NO 8U) &+`✓ 6 L Z . C// y3 .6 � v'� c'T'�� a Plumbing Code and/or Sec of the STATE LIC FINAL O LICENSE NO. `'� �� O CLASSC-24 �� pgiE 7 VALIDATION B 8 P Code for the following reason NO. DESCRIPTION OF WORK FEE li A V o HOUSE SEWER CONNECTING TO FINAL H DatePUBLIC SEWER BY SEPTIC TANK SEEPAGE PIT OR W a Signot PITS AND OR DRAINFIELD Fn NER-BUILDER DERA710 HOUSE SEWER CONNECTING TO 1111111.PRIVATE DISPOSAL SYSTEM I hereby firm that I am exempt fr the Contractor's License CONNECT ADDITIONAL BLDG OR Law for the following reason (Secton 7031.5, Buisness and Pro- WORK To HOUSE SEWER OVERFLOW SEEPAGE PIT DRAWFIELD fessions Code)- EXTN CESSPOOL DRYWELL MANHOLE _ ❑ I, as owner of the property, or my employees with wages as ALTER REPAIR OR ABANDON HOUSESEWER OR DISPOSAL SYSTEM OZ! their sole compensation, will do the work and the structure Is nor intended or offered for sale (Section 7044, Business and Professions Code). ❑ I, as owner of the property, am exclusively contracting with licensed OWNER'S contractors to construct the project (Section 7044, Permit $ Business and Professions Code). AUTHORIZATION TOTAL FEE CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). SIGNED THIS DAY OF OWNER OR Lender's Name OWNERS AGEN 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 regulating Plumbing and Sewers, and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE J