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HomeMy Public PortalAbout5827 ALESSANDRO AVE_Sewer__ WORI(,ERS' COMPENSATION DECLARATION 'L"' 76A642 DPW 3/87 T hereby,affirm that t have a certificate of consent to self insure, pr d certificate of Workers'Compensation Insurance, or 08 D CE 8 a certified copy thereof (Sec. 3800, Lab C. oe ®®PLIC® Policy No. Company ©s A i Y%TI nl FOR PERMIT ❑ Certified copy is hereby furnished. SEWER.m SEWAGE DISPOSAL ❑ 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' BUILDING Jr 2 �1.�SS�}P)DIZ� A� STATION DEPTH j COMPENSATION INSURANCE ADDRESS (This section need not be completed if the work involved by the LOCALITY MANHOLE REFERENCE [tom a LOWER permit is for one hundred dollars ($100)or less.) NEAREST TYPE OF CO NNE TION LENGTH M w� I certify that in the performance of the work for which this ceoss ST. S L.A" �u�AS ��• y Y. RB P.L. M.L.TO P.L. permit is issued, I shall not employ any person in any manner �� L�Aa�' so as to become subject to the Workers'Compensation Laws. P.C.No. I P - OWNER AVECO.IMP.NO. JOB NO. MAIL Q�9 ALE A • 1 TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS o L ^,.p NOTICE TO APPLICANT: If, after makingthis Certificate of + TH\t fIE �t 20�2g 2F57 AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE CITY TEL.NO. Exemption, you should become subject to the Workers' LEGAL `7 Compensation provisions of the Labor code, you must forthwith [ENSE CRIPTION LOT NO. /�' HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed / revoked. CK TRACT 6 5Q STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION �/2- � NO.OF BLDGS. PERMIT NO. E OF LOT �!� Z4�O NOW ON LOT b I hereby affirm that I am licensed under provisions of Chapter OF �/ 'e9 (commencing with Section 7000) of Division 3 of the Busi- LDINGS S�N�1« FQM 11 7 pr",� CHARGES ness and Professions Code, and my license is in full force andO1ifs,E�effect. NTRACTOR W N CONNECTION CHARGE FEE License Number LIC.Class DRESS REIMBURSEMENT FEE0 CantraCTOr Date DISTRICT NO. GROUP MAP PROCESSED BYY TEL.NO. gK PG ❑ I am exem t under Sec. of the L.A.Co. rE Llc.P NO. CLASS No. DESCRIPTION OF WORK FEE F- Plumbing Code and/or Sec. of the FINAL U HOUSE SEWER CONNECTING TO 'N DATE VALIDATION W B. & P. Code for the following reason 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 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 fessions Code): SEWER OR DISPOSAL SYSTEM I,as owner of the property, or my employees with wages as A,'`' a El their sole compensation, will do the work and the structure ?' ,^3; is not intended or offered for sale (Section 7044, Business and Professions Code). OWNERS Permit g �ITEII'j ❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE 3 1 u fRiL 34 -'50 licensed contractors to construct the project (Section 7044, fl 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. i'"r..i;,, �"'� r'-• CONSTRUCTION LENDING AGENCY r _ SIGNED THIS DAY OF 19_ I hereby affirm that there is a construction lending agency ® 'I•=�= for the performance of the work for which this permit is OWNER OR issued (Sec. 3097, Civ. C.). OWNERS AGENT ADDRESS Lender's Name Lender's Address . ._.:::itj 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 auth rize representatives of this County to enter upon th Qtzve- ntion /property for ins p tion purposes. TD' 7 ignature o rmi ee Date SEE REVERSE FOR EXPLANATORY LANGUAGE