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HomeMy Public PortalAbout5926 ALESSANDRO AVE_Sewer__ WORKERS'COMPENSATION DECLARATION hers ,*affirm that I have a certificate of cor-sent to slelf insuro,.ora certificate of Workers'Compensation Insurance, or 76A642D it WP � a certified co thereof Sec. 3800, Lab C. CE 808(REV.8/81) f copy ( ' APPLICATIOI PERMIT ' Pol;„y Sao. Company ©s �/�� P'Gertified copy is hereby furnished. SEWER - SE.�;1►ACit,DISPo;SAL ® Certified copy is filed with the county building in pection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Date�Applicant FOR APPLICANT TO FILL IN �, CONNECTION DATA CERTIFIC TE OF EXEMPTION FROM WORKERS' BUILDING COMPENSATION INSURANCE ADDRESS STATION F:.K DEPTH (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. CURB 'P.I. M.L.TO P.L. permit is issued, I shall not employ any person in any manner y. so as to become subject to the Workers'Compensation Laws. P.C.NO. OWNER C CO:-IMP.'NO. JOB NO. MAIL Date Applicant ADDRESS : ,.TRUNK PERMIT NO. ROAD PERMIT NO. �� NOTICE TO APPLICANT: If, after makingthis Certificate'of ! AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE CIT /—TEL.NO 2�3 Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the Labor code, you must forthwith ` P P Y DESCRIPTION LOT NO. comply with such provisions or this permit shall be deemed �,;;-};-�,. ;, . : HWY.OR ST.WIDENING ' revoked. BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO.SIZE OF LOT NOW ON LOT,BLDGS. {,;.,i'V PERMIT NO. ',:'_;"'a1• �.;;r. I hereby affirm that I am licensed under provisions of Chapter USE OF 9 (commencing with Section 7000 of Division 3 of the Busi- ( g ) BUILDINGS CHARGES ness and Professions Code, and my license is in full force andt 9 ; effect. �J CONTRACTOR CW _ CONNECTION CHARGE FEE A License Number G O LIC.CIa55/ G Z� ADDRESS Z REIMBURSEMENT FEE Contracto Date ^ L � DISTRICT NO. GROUP MAP PRO ESSED BY CITY TEL.NO. 23 BK PG TA0 ElI am exempt under Sec. of the L.A.Co. LICENSE NO.12-6 7 CLASS Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL U HOUSE SEWER CONNECTING TOPUBLIC SEWER /� DATE VALIDATION @s s 10V B. & P. Code for the following reason g SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIELD - Date HOUSE SEWER CONNECTING TO BY o PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER .r {''• <'•:.' :: OVERFLOW SEEPAGE PIT,DRAINFIELD hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Sefton 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 it 6-4 23 C;. 3C;. their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNERS Permit ❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO / I� Business and Professions Code). CONNECT THE.ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. U CONSTRUCTION LENDING AGENCY , I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_ for the performance of The work for which this permit is OWNER OR issued (Sec. 3097, Civ. C.). A OWNERS AGENT ,L!/ Lender's Name ADDRESS 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 the above-mention property for inspection purposes. Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE