HomeMy Public PortalAbout6148 AVON AVE_Sewer__ WORKERS' COMPENSATION DECLARATION
6A64
I here'Ay offirm that I have a certificate of consent to self 7T DPW 6189
insure,br a certificate of Workers' Compensation Insurance, or 6A642D
a cer*iled,copy thereof (Sec. 3800, Lab C. APPLICATION FOR PERMIT
Policy No., Company
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES -BUILDING ANR.,SAFETY
department. �' N -
Dote Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING ! d v®n 1 a� STATION DEPTH
COMPENSATION INSURANCE ADDRESS �T,r� L N TJ
(This section need not be completed if the work involved by the LOCALITY /�V f Q MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOWER
NEAREST
I certify that in the performance of the work for which this CROSS ST. -0 pp � TYPE OF CONNECTION LENGTH FROM
�- � /V Y CURB PL ML TOP t
permit is issued, I shall not employ any person in any manner LEGAL PC NO
so as to become subject to the Workers'
Compp+e�nsation Laws. DESCRIPTION LOT NO. CO IMP NO JOB NO
Dote 16' Z Applicant /T. V - CQ AS•. BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
NOTICE TO APPLICANT: If, offer making this Certificate Of
AS
AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
9 MAP BOOK S PAGE®® PARCEL®��O
Exemption, you should become subject to the Workers' No.OF 6LDGS.
Compensation provisions of the Labor code, you must forthwith SIZE OF LOT S� NOW ON LOT HWY OR ST WIDENING
comply with such provisions or this permit shall be deemed USE OF (f r
revoked. BUILDINGS Lr- p� STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION PERMIT NO
I hereby affirm that I am licensed under provisions of Chapter OWNER 42f9— G14u U-nr-T+f�
9 (commencing with Section 7000) of Division 3 of the Busi- MAIL �,
ness and Professions Code, and my L^
license is in full force and ADDRESS �f< (��f� CHARGES
effect. 7 (� / CITY Uec TEL.NO.� rg� s CONNECTION CHARGE FEE
License Number gdl gJ7o Lic.Class / REIMBURSEMENT FEE
QQ 'f `V7- ` p CONTRACTOR • Co
Contractor/T. v• ��/Kb • Date FO's fJ^�� A DISTRICT NO GROUP MAP PROCESSED BV
ADDRESS � _L K U BK PG
❑ I am exempt under Sec. of the L.A. Co. r
CITY I&V TEL.NO - ,IJ� r O
Plumbing Code and/or Sec. of the STATE LIC. FINAL U
LICENSE NO. 051 CLASS J3 DATE VALIDATION
B. & P. Code for the following reason NO. DESCRI TION OF WORK FEE � Z
O
HOUSE SEWER CONNECTING TO FINAL H
Date PUBLIC SEWER BY U
SEPTIC TANK SEEPAGE PIT OR W
Signature PITS AND OR DRAINFIELD 4.
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 d d r
OVERFLOW SEEPAGE PIT.DRAINFIELD `-"•t=`✓1 »T:
feSSiOnS Code): EXTN CESSPOOL.DRYWELL,MANHOLE
❑ I, as owner of the property, or my employees with wages as ALTER. REPAIR OR ABANDON HOUSE ^:i:_ Ti »�-
their sole compensation, will do the work and the structure SEWER OR DISPOSAL SYSTEM
is not intended or offered for sale (Section 7044, Business -
and Professions Code). _F -
❑ I, asowner of the property, am exclusively contracting with
licensed contractors to construct the project (Section 7044, OWNERS Permit
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 THISDAY OF 19_ `7/f*
OWNER OR
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 laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
Upon the above-mexted property for inspection purposes.
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE