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HomeMy Public PortalAbout4845 ARDEN DR_Sewer__ WORKERS' COMPENSATION DECLARATION I^hereby affirm that I have a certificate of consent to self 76A642 DPW 3/87 insure, or a certificate of Workers'•Compensation Insurance, or CE 808 D a cert cQpy�t r (Jec 3800, Lab C.) /�_ CE 808 APPLICATION FOR PERMIT Policy No. Company `-j�'�AK!c Am�2/cA ©s r+ 6 '( El 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 OeAkGl FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDINGl/ STATION DEPTH COMPENSATION INSURANCE ADDRESS �] V (This section need not be completed if the work involved by the / MANHOLE REFERENCE UPPER LOCALITY permit is for one hundred dollars ($100)or less.) L LOWER 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. OWNER (,LJ� (� CO.IMP.NO. JOB NO. MAIL TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS 313 LJII NOTICE TO APPLICANT: If, after makingthis Certificate Of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE CITY � TEL.NO. � � 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 Busi- BUILDINGS CHARGES ness and Professions Code, and my license is in full force and effect. ` CONTRACTORS Q7----1J CONNECTION CHARGE FEE License Number $ -f LIC. ass -y 0 ClADDRESS �`1! .{j ,GL.�' � "h��(� REIMBURSEMENT FEE p Contracl0%��e//i'� Date �'�5 CITY 6C..>�//Ot TEL.NO. �.SS Q DISTRICT NO. GROUP MAP PROCESSED BY (� Q J/ ter' BK PG � ❑ I am exempt under Sec. of the L.A.Co. LICENSE No . S/6 (7 � c ASS �) C O NO. DESCRIPTION OF WORK FEE CC99 Plumbing Code and/or Sec. of the FINAL HOUSE SEWER CONNECTING TO / DATE B. & P. Code for the following reason VALIDATION W PUBLIC SEWER N 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 Law for the following reason (Secton 7031.5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE ` fessions Code): SEWER OR DISPOSAL SYSTEM ❑ I,as owner of the property, or my employees with wages as S their sole compensation, will do the work and the structure is not intended or offered for sale Section 7044, Business and Professions Code)., OWNER'S Permit $ r-;z 44 _.._ ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION I TOTAL 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 that there is a construction lending agency SIGNED THIS DAY OF 19_ ► �.( ;-;1'•ykw c_. for the performance of the work for which this permit is OWNER OR issued (Sec. 3097, Civ. C.). OWNERS AGENT ADDRESS •sow;a.•; ±",i '" e t!;-r:: Lender's Name _ 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. '15'gnature of Permitt Date SEE REVERSE FOR EXPLANATORY LANGUAGE