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HomeMy Public PortalAbout4839 ARDEN DR_Sewer__ WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a cgrtificate of consent to self 76A642 DPW 3/87 76A642D insure, or o certificate of Workers'Compensation Insurance, or CE 808 a certified_cop oeP3800nA ��_ )S fo^ ©5 APPLICATION FOR PERMIT Policy / ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL Certified copy is filed with the county building insp--e££_tion COUNTY OF LOS ANGELES BUILDING AND SAFETY department. �1 aApplicant 6) FOR APPLICANT TO FILL IN CONNECTION DATA Date S--7- CERTIFICATE OF EXEMPTION FROM WORKE&T BUILDING Q COMPENSATION INSURANCE ADDRESS83 J ` STATION DEPTH (This section need not be completed if the work involved by the MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100) or less.) LOCALITY L� Z LOWER NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST. Y. CURB P.I. M.I.TO P.L. permit is issued, I shall not employ any person in any manner P.C.No. so as to become subject to the Workers' Compensation Lows. OWNER Ltkil P CO.IMP.NO. JOB NO. Date Applicant MAILRESS � z7, ftW � � TRUNK PERMIT NO. ROAD PERMIT NO. ADDAFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTICE TO APPLICANT: If, after making this Certificate of CITY A TEL.NO. �Qf D 6 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 PERMIT NO. LOT 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 y ) effect. �y / r CONTRACTOR ��NQ �l� �( `� CONNECTION CHARGE FEE License Number q' 63S LIC.Class TAs��i q� ADDRESS 76� �s s� T REIMBURSEMENT FEE O Contract-?WhQAi �k�T Date / CITY �,J TEL.N DISTRICT NO. GROUP MAP PROCESSED BY V STATE (`'' LIC. BK PG 0 ❑ 1 am exempt under Sec. of the L.A.Co. LICENSE NO. 116 �y CLASS ` /�A�� O lig- Plumbing Code Code and/or Sec. of the NO. I DESCRIPTION OF WORK FEE FINAL HOUSE SEWER CONNECTING TO DATE VALIDATION B. 8 P. Code for the following reason PUBLIC SEWER Z6'�2Cn SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR Poo.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 y Law for the following reason (Secton 7031.5, BUisness and Pro- ALTER,REPAIR OR ABANDON HOUSE ? fessions Code): SEWER OR DISPOSAL SYSTEM ❑ 1, as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure L t"S'7ti s; is not intended or offered for sale (Section 7044, Business and Professions Code). OWNERS Permit $ o2 ❑ 1,as owner of the property,am exclusively contracting with AUTHORIZATIONTOTAL FEE - - 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 I hereby affirm ere s a construction enaffithat there is lending agency SIGNED THIS DAY OF 19_ Y for the performance of the work for which this permit is OWNER OROWNERS AGENT issued (Sec. 3097, Civ. C.). - ADDRESS Lender's Name Lender's Address s_ti _1:.— I r,-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. J= 2 -t Signature of Perrr a Date SEE REVERSE FOR EXPLANATORY LANGUAGE