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HomeMy Public PortalAbout4841 ARDEN DR_Sewer__ WORKERS' COMPENSATION DECLARATION I•hereby affirm that I have a certificate.of consent to self 92-0002 DPW 3/87 insure, or a certificate of Workers'Compensation Insurance, or 76A642D a•certifi .- Ther o c�3800, Lab C.) ,q CE 808 APPLICATION ®R PERMIT Policy o. i��77 dlhpony MZASkM?Pi f� ©s ❑ Certified copy is hereby furnished. SEINER - SEWAGE DISPOSAL Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Date c5_—7— Applicant 111gki 01-bW7 FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDINGSTATION DEPTH COMPENSATION INSURANCE ADDRESS,¢ B (This section need not be completed if the work involved by the y. L MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) LOCALITY G(N� LOWER I certify that In the performance Of the work for which this CROSSSST. TYPE OF CONNECTION LENGTH FROM �. Y. CURB P.L. M.L.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. I P . OWNER � CO.IMP.NO. JOB NO. MAIL r � / Q, , TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS ' r .JJ V 4 `- NOTICE TO APPLICANT: If, after making this Certificate O{ r ��� `� 6� AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE g CITY TEL.NO. Com- e 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 Lor 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 ��,�C effect. CONTRACTOR J C.E 11�-� (•Q L CONNECTION CHARGE FEE License Number ic.Cl.SSADDRESS 17 0J_6 _S S-' 06 REIMBURSEMENT FEE O Cantracta �,�V Date v /7'�13� CITY C IJ A TEL.NO. sg� 13DISTRICT NO. GROUP MAP PROCESSED BYSTATELIC. V f El am exempt Under Sec. of the L.A.Co. LICENSE NO. CLASS _ �©(i 2 BK PG ��L. � 0 Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL d J w HOUSE SEWER CONNECTING TO DATE / VALIDATION PUBLIC SEWER �0 I L' L L B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR v PITS AND/OR DRAINFIELD FINAL Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER I hereby affirm that I am exempt from the Contractor's License OVERFLOW SEEPAGE PIT,DRAINFIELDEXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Sectors 7031.5, Bulsnes5 and Pro- ALTER,REPAIR OR ABANDON HOUSE :'3 fessions Code): SEWER OR DISPOSAL SYSTEM ❑ I,as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business f'- `= 'J_ and Professions Code). OWNER'S Permit g ,;;r AUTHORIZATION ❑ I,as owner of the property,am exclusively contracting with TOTAL FEE �j, licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO I#-t[?;T o ' a�. ce -.f s. Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. _`��„ CONSTRUCTION LENDING AGENCY P»'t•r: _ _ 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 >_i"fi?i?!?` „_•• 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 0k; AN � =5" 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. � 2(2 J'--242- Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE