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HomeMy Public PortalAbout5946 ALESSANDRO AVE_Sewer__ WORKERS COMPENSATION DECLARATION 0051 DPW 6189 I hereby affirm that I have a certificate of consent to self 20 20005 D Insure or a certificate of Workers Compensation Insurance orj Pol�erti ie �ppy� re f oSec p 3800 ob APPLICATION FOIL PERMIT L[J Certlfleed copy Is hereby furnished3—/—f SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY deport ent Date f/ ✓ Apphcont/��__ / � FOR APPLICANT TO FILL IN CONNECTION DATA CERT FICATE OF EXEMPTION FROM WORKERS BUILDING 7 V, COMPENSATION INSURANCE ADDRESS E STATION —/—,;:? 5 DEPTH (This section need not be completed If the work Involved by the LOCALITY MANHOLE REFERENCE �i ITUPPER permit Is for one hundred dollars ($100)or less ) ' W I certify that In the performance of the work for which this NEAREST TYPE OF CONNE TION NGTH FROM CROSS ST y U g p L M L TO P L I 77 permit is Issued 1 shall not employ any person In any manner LEGAL PC NO so as to become subject to the Workers Compensation Laws DESCRIPTION LOT NO CO IMP NO JOB NO Date Applicant BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO NOTICE TO APPLICANT If after makingthis Certificate Of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE MAP BOOK PAGE PARCEL Exemption you should become subject to the Workers NO OF BLDGS Compensation provisions of the Labor code you must forthwith SIZE OF LOT NOW ON LOT HWY OR ST WIDENING comply with such provisions or this permit shall be deemed USE OF revoked BUILDINGS STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION PERMIT NO� J I hereby affirm that I am licensed under provisions of Chapter OWNER L 9 (commencing with Section 7000) of Division 3 of the Busi MAIL CHARGES ness and Professions Code and my license is In full force and ADDRESS effect y CITY TEL NO CONNECTION CHARGE FEE License Number 694/2313 Lic Class `fLJ 9 � x � REIMBURSEMENT FEE COntrOCt./yfba &%6,10W .7 Dai. IX- 4d CONTRACTOR C f DISTRICT NO GROUP MAP PROCESSED BY ADDRESSPG BK ❑ I am exempt under Sec of rhe L A Co !,✓ p CITY(� TEL N / ��/ /�� i� 0 Plumbing Code and/or Sec of the STATE IC FINAL V LICENSE NO `� CLASS DATE ^' 1�_ VALIDATION ZZ B & P Code for the following reason NO DESCRIPTION OF WORK FEE ( 1 HOUSE SEWER CONNECTING TO FINAL Irl V Date PUBLIC SEWER BY Ll SEPTIC TANK SEEPAGEPIT OR /' W CL Signature PITS AND OR DRAINFIELD A{ CT.4 OWNER BUILDER DECLARATION HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 33Q3 cV f I hereby affirm that I am exempt from the Contractor s License CONNECT ADDITIONAL BLDG OR Low for the following reason (Secton 7031 5 Buisness and Pro WORK TO HOUSE SEWER �jE�� OVERFLOW SEEPAGE PIT DRAINFIELD fessions Code) EXTN CESSPOOL DRYWELL MANHOLE❑ ( ALTER REPAIR OR ABANDON HOUSE O © T� tiL �� ® 05 I as owner of the property or my employees with wages OS SEWER OR DISPOSAL SYSTEM their sole compensation will do the work and the Structure CHECKcp Qc Is not intended or offered for sale (Section 7044 Business t and Professions Code) (PANGE CO ❑ I Os owner of the property am exclusively contracting with OWNERS Permit $ licensed contractors to construct the project (Section 7044 Business and Professions Code) AUTHORIZATION TOTAL FEE 0000-0001 7!I ;/9b CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO // t iF I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THF PUBLIC SEWER ® 7494 1 Ft�{t 5 11, for the performance of the work for which this permit is Issued (Sec 3097 Civ C ) SIGNED THIS DAY OF 19_ OWNER OR Lender s Name OWNERS AGENT Lender s Address 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 mentioned prop rt for inspection purposes ir� 96' Signature of Permittee Dote SEE REVERSE FOR EXPLANATORY LANGUAGE