HomeMy Public PortalAbout5802, 5808-10 ALESSANDRO AVE_Sewer__ .WORKERS COMPENSATION DECLARATION /
i hereby(affirm twat I have a certificate of consent to self ll
,nauiq ora certificate of Workers Compensation Insurance or 76Ao42D U
' ,oRert,f,e ca y theye C( e a Lab C CE808(REV 1/83) APPLICATION FOR PERMIT
�❑ SF1,W,ed copy ,s hereby furnished SEWER - SEWAGE; DISPOSAL
Certif, dA�aplsled with the county building inspect n COUNTY OF LOS ANGELES BUILDING AND SAFETY
dep mIIcantALt,/ FOR APPA NT TO FILL IN S CONNECTION DATA
CE PR9 IFICATE OF EXEMPTION FROM WORKERS BUILDING
COMPENSATION INSURANCE ADDRESS �+ STATION DEPTH
(This section need not be completed,f the work involved by the ( MANHOLE REFERENCE UPPER
permit ,s for one hundred dollars ($100)or less ) LOCALITY ` LOWER
I NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that In the performance of the work for which this caos Y CURB P L MIL TOPIL
permit is Issued I shall not employ any person In any monner
so as to become subject to the Workers Compensation Laws OWNER jZ/ CO IMP NO P c NO
JOB NO
MAIL
Date Applicant ADDRESS TRUNK PERMIT NO ROAD PERMIT NO
NOTICE TO APPLICANT If after making this Certificate of CITY TEL NO AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
Exemption you should become subject to the Workers LEGAL
Compensation provisions of the Labor code you must forthwith DESCRIPTION LOT NO HWY OR ST WIDENING
comply with such provisions or this permit shall be deemed
revoked BLOCK TRACT STATE ENCROACHMENT I r
T NO
NO OF BLDGS PERMI
J
LICENSED CONTRACTORS DECLARATION SIZE OF LOT NOW F B Lot
1 hereby affirm that I am licensed under provisions of Chapter USE of
9 (commencing with Section 7000) of Division 3 of the Buss BU CHARGES
ness and Professions Code and my license is
ii)JJn) full force and
effec `y/ CONTRACTOR /1 CONNECTION CHARGE FEE
LiceTb �� C CIaSS ADDRESS REIMBURSEMENT FEE
PG
ATE IV W
LIC
nirDate DISTRICT NO GROUP MAP PROCESSED BY 0.
CI
'1 am exempt under ec oft e L A Co LICENSE NO CAS �C/J d ��� �.,BK /��
No DE RIPTION OF WORK' FEE v e O
Plumbing Code and/or Sec of the FINAL VALIDATI N
HOUSE
SEWER OUSE SEWER CONNECTING TO DATE
P
13
B 8 P Code for the following reason i W
SEPTIC TANK SEEPAGE PIT OR FINAL 0"
PITS AND/OR DRAINFIELD y
Date HOUSE SEWER CONNECTING TO BY Z
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG OR ,
OWNER BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT DRAINFIELD
I hereby affirm that I am exempt from the Contractor s License ExTN CESSPOOL DRYWELL MANHOLE
Law for the following reason (Secton 7031 5 Buisness and Pro ALTER REPAIR OR ABANDON HOUSE 1 4 5.7 A
fessions Code) SEWER OR DISPOSAL SYSTEM
ElI as owner of the property or my employees with wages as # 0 0 0 0 1 0
their sole compensation will do the work and the structure 0 0 21 5 0
is not intended or offered for sale (Section 7044 Business
and Professions Code) OWNER S Permit $ (�
ElI as owner of the property am exclusively contracting with AUTHORIZATION FEE E 0 0 0 2 1 5 0,5
licensed contractors to construct the project (Section 7044 , HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER 0 1 3 1 —8 5
CONSTRUCTION LENDING AGENCY ,
I hereby affirm that there is a construction lending agency SIGNED THIS DIAYOF 19_
for the performance of the work for which this permit is OWNER OR
issued (Sec 3097 Civ C ) OWNERS AGENT
ADDRESS
Lender s Name
r
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 Sewer
an ereby authorize representatives oft unty to a er
u n the a mentionedpro for SEP ton purp s
4��
azure of Per nee D SEE REVERSE FOR EXPLANATORY LANGUAGE