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HomeMy Public PortalAbout5431 BALDWIN AVE_Sewer__ (2) IRS'COMPENSATION DECLARATION I\ r4hat I have a certificate of consent to self insula Y� nr Ificate of Workers'Compensation Insurance, or 76A642D u a tertied co thereof (Sec. 3800, qb C. �+ CE 808(REV.8/81) APPLICATION FOR PERMIT policy No. Company. ' ©s ❑•Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL [KCR/fified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY de artment. Date -Z Applicant DHJnn�� 1745- (00U97-- FOR APPLICANT TO FILL IN CONNECTION DATA f�. I A47 CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION , G S DEPTH �� COMPENSATION INSURANCE ADDRESS -! ) ���JJJ (This section need not be completed if the work involved by the LOCALITY 1 Ell�L�� C J MANHOLE REFERENCE �g OPER permit is for one hundred dollars ($100)or less.) �y I certify that In the performance of the work for which this CROSSSST. 1-11 Va— TYPE OF CONNECTION CURB P.L. M.L.TO P.L.LENGTH FROM ' permit is issued, I shall not employ any person in any manner Y. so as to become subject to the Workers' Com ensation Laws. �j� P.C.NO. I � OWNER � IL/V�p�� J� n CO.IMP.NO. I � ,� JOB NO. Date�Applicant /�-a.i MAIL ADDRESS ��r-ott i r(k 1�j�o TRUNK PERMIT NO. ROAD PERMIT NO. NOTICE O A PLICANT: If, after makin this Certificate of e AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE g CITY �, TEL.NO. Q-[ 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 NO.OF BLDGS. PERMIT NO. SIZE OF LOT NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter i 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 r 13MC ON / CONNECTION CHARGE FEE effect. � CONTRACTOR A- � License Numb/eyyet-/^/ pn-' 71 Lic.Class ��jJ ADDRESS `tf- `/Q Cir� REIMBURSEMENT FEE 0 Contractor D,"'0 ,"fZO; Date - Z/ 0 CITY C TEL.NO. a7 /!6 DISTRICT NO. GROUP MAP PROCESSED BY g /��/yJ BK PG ❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. l C TATE ASS V V 3 `� Plumbing Code and/or Sec. of the NO. DES RIPTION OF WORK FEE UFINAL VALI ATION Em HOUSE SEWER CONNECTING TO - DATE B. 8 P. Code for the following reason PUBLIC SEWER SEPTIC TANK,SEEPAGE PIT OR FINAL g PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD , ,ACCTe4 I 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, ABANDON HOUSE fessions Code): wR DISPOSAL 07 27.50 , 1 ITEMS ❑ I, as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure TOTAL ''- ` 7 r1D is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S Permit $ �0 �� CHECX 27.!d-'l ❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE 1-27 (�(, 'l licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO CHANGE .00 Business and Professions Code). CONNECT THE ABOVE DESCRI ED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY �- I hereby affirm that there is a construction lending agency SIGNED THIS -f"2- 190 , j�{}(��( ('' fj p i OWNER OR WD_0001 7/ 1/39 for the performance of the work for which this permit is OWNERS AGENT issued (Sec. 3097, Civ. �m ], ��v� 5464 1 A�11f:4 K ADDRESS � Lender's Name , Lender's Address '/7 6& P �(� /n I certify that I have read this application and state that the ���/ cam/ r 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 t bove-mentioned property r inspection purposes. af� eIZI Si nature of Per ttee Date SEE REVERSE FOR EXPLANATORY LANGUAGE