HomeMy Public PortalAbout6262 AVON AVE_Sewer__ WORKERS COMPENSATION DECLARATI(7N A
CE 808 (�80) APPLICATION FOR PERMIT r�
CE 808 �]
I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPO
Insure or a certificate of Workers Compensation Insurance or
a certified copy thereof(Sec 3800 Lab C) COUNTY OF LOS ANGE ES I SAFETY
Policy No Company
FOR APPLICANT TO FILL IN CONNECTZN D TA
❑ Certified copy is hereby furnished
BUILDING STATION DEPTH
Certified copy is filed with the county building Inspection ADDRESS AJ Avon A\w-
UPPER
department LOCALITY MANHOLE REFERENCE
LOWER
Date Applicant NEAREST TYPE OF CONNECTION LENGTH FROM
CERTIFICATE OF EXEMPTION FROM WORKERS cRoss ST Y CURB P L M L TO P L
COMPENSATION INSURANCE P C NO
OWNER D. S CO IMP NO JOB NO
MAIL
(This section need not be completed if the work involved ADDRESS J4q Qn vQ TRUNK PERMIT NO ROAD PERMIT NO
by the permit is for one hundred dollars (5100) or less) 0
� � AFFIDAVIT WAVER EASEMENT RECORD INSTR NO DATE O
I certify that in the performance of the work for which this CIT LEGAL r�� TEL No
permit Is issued I shall not employ any person in any manner DESCRIPTION LOT NO HWY OR ST WIDENING tr
so as to become subject to the Workers Compensation Laws 0
BLOCK TRACT STATE ENCROACHMENT U
PERMIT NO
Date Applicant q.5--NO OF BLDG d
NOTICE TO APPLICANT If after making this Certificate of SIZE OF LOT.53 J Now ON LOT
Exemption you should become subject to the Workers USE OF
Compensation provisions of the Labor Code you must forth BUILDINGS S�Y1 e rt CHARGES Z_
with comply with such provisions or this permit shall beCONNECTION CHARGE FEE
deemed revoked CONTRACTOR r
LICENSED CONTRACTORS DECLARATIONADDRESS REIMBURSEMENT FEE
I hereby affirm that I am licensed under provisions of Chapter DISTRICT NO GROUP MAP PROCE ED BY
9 (commencing with Section 7000) of Division 3 of the Busl CITY TEL NO BK PG
ness and Professions Code and my license Is in full force and STATE LIC
effect LICENSE NO CLASS / O
NO DESCRIPTION OF WORK FEE
License Number LIC Class HOUSE SEWER CONNECTING TO FINAL DATE 7'�� VALIDATION
PUBLIC SEWER
SEPTIC TANK SEEPAGE PIT OR
Contractor Date PITS ANO/OR DRAINFIELD
FINAL
HOUSE SEWER CONNECTING TO BY �(„-�v+�•ry��
Q PRIVATE DISPOSAL SYSTEM v
I am exempt from the licensing requirements as I am a
CONNECT ADDITIONAL BLDG OR
Ilcensed architect or a registered professional engineer WORK TO HOUSE SEWER
acting in my professional capacity (Section 7051 Bus OVERFLOW SEEPAGE PIT DRAINFIELD
mess and Professions Code) EXTN CESSPOOL DRYWELL MANHOLE
ALTER REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
LIc or Reg No Date
HOME OWNER BUILDER DECLARATION _
I hereby affirm that I am exempt from the Contractors OWNERS Permit f
License Law for the following reason (Section 7031 5 Busl AUTHORIZATION TOTAL FEE 91 -465A
ness and Professions Code) I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON # DID O O 1
0
1RACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
I as owner of the property will do the work and the TO THE PUBLIC SEWER 2 O o 1 [� 0
structure Is not Intended or offered for sale (Section SIGNED THIS DAY OF 19_
7044 Business and Professions Code) OWNER OR 1 0 0 U
OWNERS AGENT O O O
CONSTRUCTION LENDING AGLNCY ADDRESS
I hereby affirm that there Is a construction lending agency 1 006 -81
for the performance of the work for which this permit is
issued(Sec 3097 Civ C)
Lender s Name '
I Lender s Add ess
I certify that I have read this application and state that the
above information is correct I agree to comply with all Courty
ordinances and State lags regulating Plumbing and Sewers
and hereby authorize representatives of this County to enter
upon the ab ve m do d pr ty for inspection purposes
0 SEE REVERSE FOR EXPLANATORY LANGUAGE
SI nature of Permittee Date