HomeMy Public PortalAbout6218 AVON AVE_Sewer__ WORKERS COMPENSATION DFCLARATION
1 hereby affirm that I have % cey tificate of consent to self
insure or a certificate of Workers Compensation Insurance or 76A642D
a certified copy thereof (Sec 3800 Lab C ) CE 808(REV 8/81, APPLICATION FOR PERMIT
Policy Nd(4224^='Rr24Compony tdOs
t ❑ Certified copy is hereby furnished SEWER - SEWAGE DISPOSAL
Certified copy Is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
deportme t
Dote�t l; Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS q
COMPENSATION INSURANCE PBUILDINGS
SS STATION ✓� DEPTH
(This section need not be completed if the work involved by the ITY � I Tr MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less ) LOWER
NEAREI certify that in the performance of the work for which this CROSSST
.� TYPE OF N ML LENGTH FROM
permit is issued I shall not employ any person in any manner Y culls P L M L To P L
so as to become subject to the Workers Compensation Laws P C NO
R CO IMP NO JOB NO
TRUNK PERMIT NO ROAD PERMIT NO
Date Applicant SS LAFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
NOTICE TO APPLICANT If after making this Certificate of L NoExemption you should become subject to the Workers ALCompensation provisions of the Labor code you must forthwith IPTION LOT NO HWY OR ST WIDENING
comply with such provisions or this permit shall be deemedrevoked TRACT STATE PERMIT NOROACHMENT ' 1193��LICENSED CONTRACTORS DECLARATION NO OF BLDGs JF LOT NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter Z9 (commencing with Section 7000) of Division 3 of the Busl NGS q ARGES
ness and Professions Code and my license is In full force and
effect t, CONTRACTOR CONNECTION CHARGE FEE
CL
License Number [727LG� LIC Class.3k 7 Z ADDRESS REIMBURSEMENT FEE Q
Contractor E jQ ?(—&(Z Date Z 2.4'e hc-w CITY D TRICT N9! GROUP MAP PR ESSED BY u
TEL NO Z� /STATEV�'AjO�/
BK PG O
El am exempt under Sec of the L A Co LICENSE NO class _ l0
Plumbing Code and/or Sec of the NO DESCRIPTION OF WORK FEE FINAL
HOUSE SEWER CONNECTING TO DATE _ VALIDA N N
B 8 P Code for the following reason PUBLIC SEWER
SEPTIC TANK SEEPAGE PIT OR FINAL
PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO BY ) 6 2[�6 A
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG OR
OWNER BUILDER DECLARATION WORK TO HOUSE SEWER # o 0 0 0 0
..
I hereby affirm that I am exempt from the Contractors License OVERFLOW SEEPAGE PIT DRAINFIELD EXTN CESSPOOL DRYWELL MANHOLE
Law for the following reason (Secton 7031 5 Buisness and Pro ALTER REPAIR OR ABANDON HOUSE I • 3 8 5 0
fessions Code) SEWER OR DISPOSAL SYSTEM
❑ I as owner of the property or my employees with wages as • • - 3&50;—'
their sole compensation will do the work and the structure
is not Intended or offered for sale (Section 7044 Business Permit g 1 231 -86
and Professions Code) OWNER S
❑ I as owner of the property am exclusively contracting with I AUTHORIZATION I TOTAL FEE l'
licensed contractors to construct the project S7044
P I ( HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
ect ection
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_
for the performance of the work for which this permit Is OWNER OR t
-
Issued (Sec 3097 Civ C ) OWNERS AGENT
ADDRESS
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 jaws regulating Plumbing and Sewers ,rT
and hereby authorize representatives of this County to enter r
Zuponabove mentioned property for inspection p&uoses `
z
IgIn ture of Per Ittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE