HomeMy Public PortalAbout6158 AVON AVE_Sewer__ WORKERS'COMPENSATION DECLARATION 7 A`642D �� �'
E808 (2-80> APPLICATION FOR PERMIT
I hereby affirm that I have a certifica of consent to self SEWER-SEWAGE DISPOSAL
insure or certificate of W r s' o sation Insurance,or
�c�r i c here j COUNTY OF LOS ANGELES BUILDING AND SAFETY
�1 y o. C mpany
FOR APPLICANT TO FILL IN CONNECTION DATA
ertified copy is hereby furnished.
BUILDING ` �'- qMANHOLE
TION DEPTH
Certified copy is filed ith the unty bLin:8ection ADDRESS / UPPER
REFERENCE LOWER
e rt t. LOCALITY
Date p licant NEAREST TYPE OF CONNECTION LENGTH FROM
CERTIFICATE OF EXEMPTION FRO ORKERS' CROSS ST Y. CURB P.L. M.L. TO P.L.
COMPENSATION INSURA CE
OWNER CO. IMP. NO. JOB NO.
MAIL
(This section need not be completed if the work involved ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO. d
by the permit is for one hundred dollars ($100) Or less.) AFFIDAVIT WAIVER EASEMENT RECORD. INSTR. NO. DATE O
CITY TEL. N •i5 U
I certify that in the performance of the work for which this LEGAL
permit is issued, I shall not employ any person in any manner DESCRIPTION LOT NO. cc
HWY. OR ST. WIDENING
so as to become subject to the Workers' Compensation Laws. 0
BLOCK TRACT STATE ENCR�Q�C �j NT
Date Applicant No. of BLD GS. PERMIT N0. 9�.i/ T t LU
SIZE OF NOW ON LOT O.
NOTICE TO APPLICANT: If, after making this Certificate of ✓ .�� to
Exemption, you should become subject to the Workers' USE o -
BUIL CHA G
Compensation provisions of the Labor Code, you must forth s
Z
forth-
with comply with SUCK provisions or this permit Shall be CONNECTION CHARGE FEE
p CONTRACTOR
deemed revoked.
REIMBURSEMENT FEE
LICENSED CONTRACTORS DECLARATION ADD SS
I hereby affirm that I am licensed under provisions of Chapter 3 DISTRICT NO. GROUP MAP PROCESSED BY
tT
9 (commencing with Section 7000) of Division 3 of the Busi-
QTEL. Nq •— BK PG
ness and Professions Code, and my license is in full force and LICENSE N
CIL "® ^ '3 /
effect' / NO. DESCR PTION OF WOI9K FEE FINAL VALIDATION
-rte,./y/ HOUSE SEWER CONNECTING TO �
License
Numb e Lic.Class C•. `/"III PUBLICDATE
SEPTIC TAANNKK,,SEEPAGE PIT OR
Co ate s PITS AND/OR DRAINFIE LD FINAL
o HOUSE SEWER CONNECTING TO BY
❑ PRIVATE DISPOSAL SYSTEM �1
I am ex pt from the licensing requirements as I am a CONNECT ADDITIONAL BLDG.OR
licensed architect or a registered professional engineer WORK TO HOUSE SEWER 91
acting in my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT,GRAINFIELD Z7�
(ness and Professions Code). EXTN..CESSPOOL, DRYWELL, MANHOLE
ALTER, REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM r
Lic.or Reg.No. Date -1
31
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's OWNERS Permit f S 0 D
License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE 56 z 3 0 S 4 A
ness and Professions Code):
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- #7O O O O 1 0
❑ TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
I, as owner of the property, will do tfie work and the TO THE PUBLIC SEWER. pQ'
structure is not intended or offered for sale (Section SIGNED THIS DAY OF - �� $1_ 2 D 'O 3,1.5 0
7044, Business and Professions Code). OWNER OR
OWNERS EN .O 0,0 3 1,5 0 2
CONSTRUCTION LENDING AGENCY wOORE
I hereby affirm that there is a construction lending agency 0 2124-82
for the performance of the work for which this permit is
issued (Sec. 3097,Civ.C.).
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 my to ater
upon the above-mentioned prop�tfns ionp'rp es.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date