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HomeMy Public PortalAbout5721 ALESSANDRO AVE_Sewer__ WORKERS' COMPENSATION DECLARATION I,,hereby'offirm uViaf I have a certificate of consent to self insure, or a certifioote of Workers'Compensation Insurance, or 76A642D a certified copy thereof (Sec. 3800, Lab C. CE 808(REV.8/81) APPLICATION FOR PERMIT Policy No. Company ©s ❑ Certified copy is hereby furnished. SEWER -'SEWAGE DISPOSAL El Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' F.U,LD,NGS ING 7� �� ,� �� COMPENSATION INSURANCE SS 5 STATION DEPTH (This section need not be completed if the work involved by the ��/OLE— �� S MANHOLE REFERENCE3,��� �.{/ 7 'y () LOPPER WER permit is for one hundred dollars ($100)or less.) LOCALITY /_Z certify that in the performance Of the Work for which this CROSSNEAREST. ���/ TYPE OF CO N LENGTH FROM Y. CURB P.L. M.L.TO P.L. permit is issued, I shall not employ any person in any manner p.c.No. so as to become subject to the Workper�s'Coimp�ens/at�io�nlL�aws./ R (JL ® E. CO.IMP.NO. JOB NO. MAILJ A licanf �/�'Tll IC4- LL �"�lVC _ MA SS 3 dC� TRUNK PERMIT NO. ROAD PERMIT NO. Date � PP e, AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTICE TO APPLICANT: If, after making this Certificate of WI V(J ��y TEL.N . 'L +- 2_ Exemption, you should become subject to the Workers' ALCompensation provisions of the Labor code, you must forthwith IPTION LOT NO. HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed revoked. TRACT STATE ENCROACHMENTLICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMITF LOT NO ON L /e m, iZ R�I hereby affirm that I am licensed under provisions of Chapter , J ✓F9 (commencing with Section 7000) of Division 3 of the Busi- INGS CHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTORIr CONNECTION CHARGE FEE @ti License Number Lic.Class ADDRESSREIMBURSEMENT FEE O DISTRICT NO. GROUP MAP PRO SSED BY (- Contractor Date CITYN/f TEL.NO. BK PG STATE LIC. J(�/ O ❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. CLASS .o R-3 Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL NJ HOUSE SEWER CONNECTING TO !7) DATE Z (/ B. & P. Code for the following reason VALIDATIO g PUBLIC SEWER SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM _ Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER I hereby affirm that I am exempt from the Contractor's License OVERFLOW SEEPAGE PIT,DRAINFIELD EXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Secton 7031.5, Bulsness and Pro- ALLER*R6PMR OR ABANDON44CIVSE fessions Code): 6EYdPR'OR DISPOSAL SYSTEM - KI,as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S Permit $ ❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE ISEWER, licensed COniraCfOrs }O construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIO'o13 CONSTRUCTION LENDING AGENCY o 0 o 'J 7.5 0 5 I hereby affirm that there is a construction lending agency SIGNED THISDAY OF for the performance of the work for which this permit is OWNER OR o-1. 05-87 issued (Sec. 3097, Civ. C.). OWNERS AGENT ADDRESS Lender's Name 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 Plumbing and Sewers, and hereby authorize representatives of this County to enter upon 11!1W above- ned pr erty for inspection purposes. _1Z,%1_97 Signature of Permittee f Date SEE REVERSE FOR EXPLANATORY LANGUAGE