HomeMy Public PortalAbout4847 ARDEN DR_Sewer__ WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self 20-0051 DPW 6189
Insure, or a certificate of Workers'Compensation Insurance, or 76A642D
a certified copy.thereof (Sec. 3800, Lab C.) APPLICATION FOR PERMIT
Policy No. 1264-166 Company State 1)i
F1Certifiedcopy Is hereby furnished. SEWER - SEWAGE DISPOSAL
IxCertified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Date 4/7/94 Applicant Integral Builders FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING Tp t N.
�y T7� ri /�
COMPENSATION INSURANCE ADDRESS 4847 N. ArCIM ER., l�e aty 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 OWER
NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CRoss sr. aor msa Y CURB P L Mt TOP L
permit is issued, 1 shall not employ any person in any manner LEGAL
so as to become subject to the Workers' Compensation Laws. DESCRIPTION LOT No. J C NO
I P CO IMP NO JOB NO
BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of MAPEBOOK 60SSOR -71
AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
260 PAGE 54 PARCEL 61524
Exemption, you should become subject to the Workers' NO.OF BLDG&
Compensation provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT HWY OR ST WIDENING
comply with such provisions or this permit shall be deemed USE OF �y,.�
revoked. BUILDINGS a 1111 C. STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION PERMIT NO
I hereby affirm that I am licensed under provisions of Chapter OWNER
9 (commencing with Section 7000) of Division 3 of the Busi- MAIL 32 N �TBI19C1C
Hess and Professions Code, and my license is in full force and ADDRESS CHARGES
effect. 627290 CITY TEL.NO. 818-282-0931 CONNECTION CHARGE FEE
License Number '.: Lic.Class B REIMBURSEMENT FEE
T,.,t�� n,''�,y,,.,� CONTRACTOR '
Contractor cite:Xal Buck-t-9ate 4/7/ p� T DISTRICT NO GROUP MAP PROCESSED BY
ADDRESS 829 S. ytLLL„✓ty A11-B SK PG
❑ I am exempt under Sec, of the L.A.Co. Walt zl 909_869-1075 �®
CITY TEL.NO. d
Plumbing Code and/or Sec, of rhe STATE LIC. FINAL V
LICENSE NO. 627290 CLASS B DATE ' VALIDATION Z
B. 8 P. Code for the following reason NO. DESCRIPTION OF WORK FEE / i✓
O
HOUSE SEWER CONNECTING TOFINAL F,
Date 1 PUBLIC SEWER Q BY (�
SEPTIC TANK SEEPAGE PIT OR 111
PITS AND OR DRAINFIELD d
Signature N
OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING TOPRIVATE DISPOSAL SYSTEM ►
I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR
Law for the following reason (Secton 7031.5, Buisness and Pro- WORK TO HOUSE SEWER i
fessions Code): OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN.CESSPOOL.DRYWELL.MANHOLE
❑ 1,as owner of the property, or my employees with wages as ALTER REPAIR OR ABANDON HOUSEv`_( u8
their sole compensation, will do the work and the structure SEWER OR DISPOSAL SYSTEM �_rt_ _
is not intended or offered for sale (Section 7044, Business 33[105 r i`
and Professions Code). )
El 1, as owner of the property, am exclusively contracting with 4Permit $ �' fp L�� I'
1 T ON S
OWNER'S '=g" � t
licensed contractors to construct the project (Section 7044, �_ I!-tt_ �' �>a
Business and Professions Code). AUTHORIZATION TOTAL FEE /.
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO -
I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER
for the performance of the work for which this permit Is
issued (Sec. 3097, Civ. C.). SIGNED THIS 7th DAY -il19-24
7��y��,,.,�� ,,,,,7� OWNER OR
Lender's Name ' llrT� S.
Natij�1cnal B31JM1��y� �, �A OWNERS AGENT
200 S. (33r-�C1d AW. AJI'JELL Xa lt1 ADDRESS �e3_7_:_ L ;y -
Lender's Address- i
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 propert f inspection purposes.
4/7/94
SignotLAe of PcVmittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE