HomeMy Public PortalAbout5934, 5934 1/2 ALESSANDRO AVE_Sewer__ WORKERS COMPENSATION DECLARATION ,
I hereby affirm that I have a certificate of consent to self l�
Insure or a certificate of Workers Compensation Insurance or 76A642D U
a certified copy thereof (Sec 3800 Lab C ) CE808(REV 1/83) APPLICATION FOR PERMIT
Policy No Company
❑ Certified copy is hereby furnished SEWER - 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
COMPENSATION INSURANCE ADDRESS / STATION 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 OWER
NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST Y CURB P L ML TOP L
permit is Issued I shall not employ any person in any manner
so as to become subject to the or ers Compensation Laws t. P C No
I p OWNER ` CO IMP NO JOB NO
1
ADDRESS a 5s TRUNK PERMIT NO ROAD PERMIT NO
twlDate Applicant
Ll/ AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
NOTICE TO APPLICANT If after makin this Certificate of CITv TEL NO `-/
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 s BLOCK TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO OF BLDGS PERMIT NO
I hereby affirm that I am licensed under provisions of Chapter SIZE OF LOT NOW ON LOT
USE OF
9 (commencing with Section 7000) of Division 3 of the Busi BUILDINGS CHARGES
ness and Professions Code and my license is in full force and �^
effect CONTRACTOR w•�Jr�i�. CONNECTION CHARGE FEE
License Number LIC Class ADDRESS11-11' REIMBURSEMENT FEE >,
Contractor Date DISTRICT NO GROUP MAP PR ESSED BY i�.
CITY TEL NO BK PG V
STATE LIC
El am exempt under Sec of the L A Co LICENSE NO CLASS SiU X-/ 09
Plumbing Code and/or Sec of the NO DESCRIPTION OF WORK FEE FINAL O
HOUSE SEWER CONNECTING TO DATEVALIDATION u
B 8 P Code for the following reason PUBLIC SEWER 7— -eT
t✓L
SEPTIC TANK SEEPAGE PIT OR d
FINAL
Date PITS AND/OR DRAINFIELD H
HOUSE SEWER CONNECTING TO
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 EOXTNFLOWSSEPOEPOL DR IWDRAIMNAFNHDOLE
Law for the fallowing reason (Secton 7031 5 Buisness and Pro ALTER REPAIR OR ABANDON HOUSE
fessionS Code) SEWER OR DISPOSAL SYSTEM � 1 7 2 4 A
El I 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 2 -"- c+ 2 1 5 0
is not Intended or offered for sale (Section 7044 Business
and Professions Code) OWNER'S Permit S C) Jo o io 2 1 5 0 c=i
❑ I as owner of the property am exclusively contracting with AUTHORIZATION TOTAL FEE d 10 6'0 4`-8 4
licensed contractors to construct the project (Section 7044 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
Business and Professions Code) CONNECT THE ABOVE DESCRIaED EXISTING DWELLING TO THE PUBLIC SEWER
CONSTRUCTION LENDING AGENCY ,
I hereby affirm that there is a construction lending agency SIGNED�AGAENT ,�-k
AYO for the performance of the work for which this permit is OWNER OOWNERS
issued (Sec 3097 Civ C )
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
u the above mentioned propArty for inspection purposes
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"` Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE