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HomeMy Public PortalAbout4843 ARDEN DR_Sewer__ WORKERS;COMPENSATION DECLARATION -P h6reby-affirm that I have a certificate of consent to self 92"0002 DPW 3/87 insure, or a certificate of Workers'Compensation Insurance, or CE 806 D a certified �r�,f,,�,( y'-6.3800, Lab C.) CE 808 APPLICATION FOR PERMIT Policy rTo'. 'iV ampany �h LQL9 ©s ❑ 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 0 STATION DEPTH /�� /L .A -� - COMPENSATION INSURANCE ADDRESS This section need not be completed if the work involved b the UPPER ( p y LOCALITY €y" � MANHOLE REFERENCE LOWER permit is for one hundred dollars ($100)or less.) 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 �d P.C.NO. so as to become subject to the Workers'Compensation Laws. OWNER Iv`,' CO.IMP.NO. JOB NO. MAIL "��`� ��y - �.•s ( TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS / ll !!/I,�tl Q W 2 AFFIDAVIT WAIVER EASEMENT RECORD INSTR.NO DATE NOTICE TO APPLICANT: If, after making this Certificate of c1Tv �a'N�} TEL.No. —7 ¢/� 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, USE OF 9 (commencing with Section 7000) of Division 3 of the BUST- BUILDINGS CHARGES ness and Professions Code, and my license is in full force and p effect. 11, CONTRACTOR 1 tom`-' 3 l CONNECTION CHARGE FEE License Nuppmbe'r �163S Lic.Class �c ADDRESS >Z 6.p g REIMBURSEMENT FEE O Contractor\(0.)&3& C ate t � 7 CITY TEL.NO. '�� DISTRICT NO. GROUP MAP PROCESSED BY O /� �• BK PG Z ❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. k !p CLASS Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINALHOUSE SEWER / U LU PUBLIC SEWER B. & P. Code for the following reason CONNECTING TO DATE \�� J VALIDATION SEPTIC TANK,SEEPAGE PIT OR FINAL 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 I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE Low for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE 4t, 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 and Professions Code). OWNERS Permit $ Tti.ri»= ❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE T _ licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO ?`•"1L-- ' Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. $s. gi--{.Ir +J •� CONSTRUCTION LENDING AGENCY k'' --N —•• - -- , :•a I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_ "•:,••�("M sj'jE�, OWNER OR ` `'�'-• for the performance of the work for which this permit is OWNERS AGENT issued (Sec. 3097, Civ. C.). ADDRESS Lender's Name r xz•1s_�;,,,•; ;-:�i; - y Lender's Address µ P JA 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. �3E ), 57-_7_9 Z Signature of Permtee Date SEE REVERSE FOR EXPLANATORY LANGUAGE