Loading...
HomeMy Public PortalAbout6008 ALESSANDRO AVE_Sewer__ V/ORKERS'COMPENSATION DECLARATION _ I 1 hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance, or 76A642D a eFT*At; to;ypttherreeo (Sec. 3800, Lab^C.) CE808(REV.1/83) APPLICATION FOR PERMIT Policy No� ompany IQ S'�• C%m ❑ Certifie ffcopy Is hereby furnished. SEWER - SEWAGE DISPOSAL Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY depa tmen . Date 51JI�Applicant 1? FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING ; STATION DEPTH /� 1 COMPENSATION INSURANCE ADDRESS , g AD t fib+ (O This section need not be completed if the work involved b the 7 ^�D ",/ t©) PPER ( P Y LOCALITY MANHOLE REFERENCE 4 '7s �.J f R permit is for one hundred dollars ($100)or less.) I certifythat in the performance Of the work for which this NEAREST TYPE OF CON N LENGTH FROM P CROSS ST. Y. CURB P.L. M.L.TOP.L. ' permit is issued, I shall not employ any person in any manner so as to become subject to the Workers Compensation LOWS. P.C.NO. I P OWNERdA �. � CO.IMP.NO. JOB NO. MAIL n,� TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS ' S' Is NOTICE TO APPLICANT: If, after makingthis Certificate of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE CITY TEL.NO. *7 Exemption„ you should become subject to the Workers' LEGAL Compensat on 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 e LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO. SIZE OF LOT NOW ON LOT �l I hereby affirm that I am licensed under provisions of Chapter USE OF 15-1 9 (commencing with Section 7000) of Division 3 of the BUS[- BUILDINGS "�j 1 CHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTOR 014 1A S ,� CONNECTION CHARGE FEE License Number Lic.Class ADDRESS REIMBURSEMENT FEE COhtraclor Date CITY TEL.NO. 3�"� DISTRICT NO. GROUP MAP PR ESSED BY ❑ 8K pis I am exempt under Sec. of the L.A.Co. LICENSE NO. E=+ O J cinss '� V` t/ �s 7 Plumbing Code and/or Sec. of the NO. D SCRIPTION OF WORK FEE FINAL. � HOUSE SEWER CONNECTING TO DATE VALIDA ION B. & P. Code for the following reason PUBLIC SEWER i SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD FINAL Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR ; - 9 ;2 2 0 7.9 A OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD # 0-0 O O , ,O 1 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 HOUSEO O 3 9 0 0 fessicns Code): SEWER OR DISPOSAL SYSTEM ❑ I,as owner of the property,or my employees with wages as0 0 0 0039. 5, their sole compensation, will do the work and the structure0 S21 -85 is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S Permit $ ❑ I, as Owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE licensed contractors to construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTR CTOR TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY , I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF IgJ_J for the performance of the work for which this permit is OWNER OWNERSAGENT +'.�rt.�1/L, 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 upon the above-mentioned property for inspe tion purposes. 6_` Signature of Permittee Dat6 SEE REVERSE FOR EXPLANATORY LANGUAGE