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HomeMy Public PortalAbout6111 AVON AVE_Sewer__ , WORKERS' COMPENSATION DECLARATION �j 4-'1 hereby affirm that ?r have a certificate of consent to self 200051 DPW 6189 U insure; or a cEviificate of Workers' Compensation Insurance, or 76A6420 a Certified copy thereof (Sec. 3800, Lab C. APPLICATION FOR PERMIT Policy No. Company ,E] 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 COMPENSATION INSURANCE ADDRESS /I 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 LOWER NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST. Y CURB PL M L TO P L permit is issued, 1 shall not employ any person in any manner LEGAL SO OS t0 become subject to the Workers' Compensation LOWS, DESCRIPTION LOT NO. PC NO CO IMP NO JOB NO Date Applicant BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO NOTICE TO APPLICANT: If, after making this Certificate Of ASSESSOR j /_ /� / AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE g MAP BOOK , 1 f V PAGED 7 PARCELO/t(o Exemption, you should become subject to the Workers' NO.OF BLOCS. 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 revoked. BUILDINGS STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION PERMIT NO I hereby affirm that I am licensed under provisions of Chapter OWNER VM 14 9 (commencing with Section 7000) of Division 3 of the Busi- MAIL ness and Professions Code, and m,/license is in full force and ADDRESS CHARGES effect. CITY TEL.NO. CONNECTION CHARGE FEE License Number Lic.Class REIMBURSEMENT FEE CONTRACTOR Contractor Date DISTRICT NO GROUP MAP PROCESSED BY ADDRESS BK PG ❑ I am exempt under Sec. of the L.A. Co. 5©� � �� 1 I J a CITY TEL.NO. i• %G�'s�—L•�'�'- O Plumbing Code and/or Sec. of the STATE LIC. FINAL 0 LICENSE NO. CLASS DATE VALIDATION B. & P. Code for the following reason NO. DESCRIPTION OF WORK FEE l Z O HOUSE SEWER CONNECTING TO FINAL Date PUBLIC SEWER "� 740 BY ~ U SEPTIC TANK SEEPAGE PIT OR UJ Signature PITS AND OR DRAINFIELD HOUSE SEWER CONNECTING TO OWNER-BUILDER DECLARATION PRIVATE DISPOSAL SYSTEM , Z I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR -1_7 Law for the following reason (Secton 7031.5, Buisness and Pro- WORK TO HOUSE SEWER fe55lOn5 Code): OVERFLOW SEEPAGE PIT.DRAINFIELD _ EXTN,CESSPOOL. DRYWELL,MANHOLE % S-'-.si.j' ❑ I, as owner of the property, or my employees with wages as ALTER REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM o •'�' m +1 0their sole compensation, will do the work and the structure is not intended or offered for sole (Section 7044, Business s is - and Professions Code). CHECK W ° I, as owner of theproperty, am exclusive) contracting with ' H I r r y g OWNER'S Permit $ �{�p 6) `�`�'���� licensed contractors to construct the project (Section 7044, Business and Professions Code). AUTHORIZATION TOTAL FEE 4 / d 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 -r_-J�-ItS�i Lf f QEr for the performance of the work for which this permit Is ® ya7iL i 't 7 II issued (Sec. 3097, Civ. C.). SIGNED THIS DAY OF 19_ OWNER OR 1 Lender's Nome OWNERS AGENT Lender's Address 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 lows re ulating Plumbing and Sewers, and her y out orize repres to,Ves of this County to enter Upon th above- e do ed p perry for inspection purposes. Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE