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HomeMy Public PortalAbout5930 AVON AVE_Sewer_8/16/1989_sewer connection y WORKERS'COMPENSATION DECLARATION heroby 'affirm that I have a certificate of consent to self'' insure, or a certificate of Workers'Compensation Insurance, or 76A642D ace�lifiedcopy thereof (Sec. 3800, Lob C.) CE 808(REV.8/81) Policy No; Company ©r- Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO, HWY,OR ST.WIDENING comply with such "provisions or this permit'shall be deemed revoked. BLOCd TRACT STATE ENCROACHMENT LICENSED.CONTRACTORS DECLARATION NO.OF BLDGS. / PERMIT No. SIZE OF LOT - NOW ON LOT Ir. - I hereby affirm that I`am licensed under provisions of Chapter USE OF 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTOR -�^, - CONNECTION CHARGE FEE License Number Lic.Class ADDRESS REIMBURSEMENT FEE - O Contractor Date �DISTRICTNO. GROUP MAP PROCESSED BY U ' - CITY TEL.NO. BK PGOLICEN LIC � ❑ 1 am exempt under Sec. of the L.A.Co. STATELICENSE No' LIC. 0 NO.. DESCRIPTION OF WORK, FEE 'V Plumbing Code and/or Sec. of the FINAL � HOUSE O DATE B. & P. Code for the following-reason - _ SEWER CONNECTING T ' - - -- PUBLIC - - - SEPTIC TANK,SEEPAGE PIT OR "PITS'AND/OR'DRAINFIELD - -- -- FINAL Date HOUSE SEWER CONNECTING TO BY, - PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR •. /ya OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER f OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE i �}7 Law for the following reason (Secton 7031.55, BUIsness and Pro- ALTER,REPAIR OR ABANDON HOUSE 3 Ft _f fessions Code): SEWER OR DISPOSAL SYSTEM T HEMS LJ I,as owner of the property,or my employees with wages as yl ?�� their sole compensation, will do the work and the structure 1 21 Le is not intended or offered for sale (Section 7044, Business nd Professions Code). OWNER'S Permit $ e � CHECK 2105£1 as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE CHANGE .130licensed COn}rOCfOrB 10 construct the project (Section 71)44, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED.CONTRACTOR TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCYiClt-0001 I hereby affirm that there is a construction .lending agency- SIGNED THIS DAY OF - 19._ vl12L sq for the performance of the work for which this permit Is, OWNER OR G issued (Sec. 3097, Civ. C.).' OWNERS AGENT ti 076 i AM 3: 10 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 laws"regulating Plumbing and Sewers, and here y authorize re sentatives of this County to•enter upo a bov mentio property or inspection purpJoos'es. �� Ignature of erm5 a IV Date. SEE REVERSE FOR EXPLANATORY LANGUAGE