HomeMy Public PortalAbout6029 ALESSANDRO AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self 92-0002 DPW 3/87
insure, cy a certificate of Wdrkers'Compensation Insurance, or' 76A642D
a certified copy thereof (Sec. 3800, Lab C. CE 808 APPLICATION FOR PERMIT
Policy No. Company its
❑ 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' FNEAREST
STATION DEPTH
COMPENSATION INSURANCE
(This section need not be completed if the work involved by the MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) NJA� LOWER
TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this Y. CURB P.L. M.L.TO P.L.
permit is issued, I shall not eatermaking
perso in any manner
so as to beco a subject to thensu ' n LOWS. OWNER �VV n� �_- CO.IMP.NO. JOB NO.
MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
Dat pplicantCo,, ADDRESS C
NOTICE T A PLICANT: If, this ertificate Of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
CITY EL NO. JF
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. BLOCK TRACT STATE ENCROACHMENT
. -
LICENSED CONTRACTORS DECLARATION NOOF BLDGS. PERMIT NO.SIZE OF LOT NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter 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 fill
CONNECTION CHARGE FEE
License Number Lic.Class ADDRESS IZ I REIMBURSEMENT FEE d
O
Contractor Date DISTRICT NO. GROUP MAP PROCESSED BY V
CITY TEL.NO. •' n BK PG
ElP I am exempt under Sec. of the L.A.Co. STATE LIC. d /�-5 O
LICENSE NO. CLASS vvv��`
NO. DESCRIPTION OF WORK FEE U
Plumbing Code and/or Sec. of the FINAL VALIDATION LU
HOUSE SEWER CONNECTING TO DATE
PUBLIC SEWER
B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR FINAL
PITS AND/OR DRAINFIELD —
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
SEWER .
Signature WORK
CONNECT
HOUSEONAL BLDG.OR / g 9 9 r� 2 A
OWNER-BUILDER DECLARATION OVERFLOW SEEPAGE PIT,DRAINFIELD [ + G Y 7 V G
I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE # o 0 0 0 .1 0
Law for the following reason (Secton 7031.5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM ' o - 2,1.50
❑ I,as owner of the property,or my employees with wages as
their sole compensation, will do the work and the structure o 0 o 21.5 0 E
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permit $ Q 616-88
❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE o2
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 DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY oil.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.). OWNERS AGENT
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 her thorize r i/es of this County to enter
upon e a e-ment' ed grope y for inspection purposes.
1 nature of Permittee Date - SEE REVERSE FOR EXPLANATORY LANGUAGE