HomeMy Public PortalAbout5319 BALDWIN AVE_Sewer__ (2) WORKERS'COMPENSATION DECLARATION f M
FCe;1'c,;q,.No'.z,.Compony
by...affirm that I have d oortificote.of consent to se#
or o certificate of Hforkam'CornOP..�otior,Insurance, or '• 76A692D
fied copythereof"'(Sec. 3800, Lab C.) 92-0002 DPW 6/88 APPLICATION FOR PERMIT
❑ 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 ra^� STATION DEPTH
(This section need not be completed if the work Involved by the MANHOLE REFERENCE UPPER
LOCALITY LOWER
permit is for one hundred dollars ($100)Of less.) NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. Y. CURB P.L. M.I.TO P.L.
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. P.C.NO.
OWNER Q CO.IMP.NO. JOB NO.
MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS / r
NOTICE TO APPLICANT: If, after making this Certificate of CITY AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
Exemption, you should become subject to the Workers' ` C TEL.No.
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 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 Busl- BUILDINGS CHARGES
ness and Professions Code, and my license is in full force and
effect. CONTRACTOR iG��- CONNECTION CHARGE FEE
License Number Llc.Class ADDRESS V V REIMBURSEMENT FEE
Contractor Date DISTRICT NO. GROUP MAP PRO CES BY Z:
CITY TEL.NO. BK PG d
El am exempt under Sec. of the L.A.Co. STATE No. LIC.CLAI
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE CL FINAL ���ppp / //
HOUSE SEWER CONNECTING TO DATE VALIDATION� ��/
B. & P. Code for the following reason PUBLIC SEWER
SEPTIC TANK,SEEPAGE PIT OR e
PITS AND/OR DRAINFIELD FINALl
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM llll//// vvv
Signature CONNECT ADDITIONAL BLDG,OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD
I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE
Law for the following reason (Sectors 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE l l
fessions Code): SEWER OR DISPOSAL SYSTEM ,,??
AUT,y
tit•.•� n 4•
❑ I,as owner of the property,or my employees with wages as - i
their sole compensation, will do the work and the structure Z307
°-4
is not intended or offered for sale (Section 7044, Business
i�
and Professions Code). OWNERS Permit $ U
❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE---9� a 4 ATL ' - 00
licensed contractors to construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO 1.j�v^��F r} }Yfl I
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. -z-s .27
11 °
CONSTRUCTION LENDING AGENCY ® ICHANGE ,00
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 y f
Lender's Name ADDRESS 0ri00-W 1 S13/90
mow
'' 5il 1 AM 9-00_i
•.
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 inspection purposes.
Signature of Permittee Date �— SEE REVERSE FOR EXPLANATORY LANGUAGE