HomeMy Public PortalAbout9084 ACASO DR_Sewer_5/23/1989_sewer connection { WORKERS'COMPENSATION DECLARATION Y
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Hereby affirm that I have a certificate of consent to self
insure, or o certificate of Workers Compensation Insurance, or 76A6421) ,
a certified copy thereof(Sec 3800, Lab C ,, rCE 808(REV 8/81) APPLICATION FOR PERMIT
Policy No ' Company _ IDS
❑ Certified copy is hereby furnished SEWER - SEWAGE DISPOSAL ,
❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES - BUILDING AND SAFETY
department ,
Date Applicant �� FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS BUILDING 6
`COMPENSATION INSURANCE ADDRESS p a G c - ji STATION DEPTH
(This section need not be completed if the work involved by the IACALITY G L �` ( MANHOLE REFERENCE UPPER
• LOWER
,
permit is for one hundred dollars ($100)or less )
I certifythat in the performance of the work for which-this NEAREST �/7 _ TYPE OF CONNECTION " 4 M L TOP L
P CROSS ST�� Q /V O �I/ Y� CURB� P L M L TOP L
permit is issued I shall not employ any person in any manner - P c No
so as to become subject to the orkers Compensation lows OWNER 7 CO IMP"NO JOB NO
,-46, _'6 / Applicant e&li , TRUNK PERMIT NO ROAD PERMIT NO
DateADDRESS � SO D��J � �V� 4 � C1
AFFIDAVIT I WAIVER EASEMENT RECORD INSTR NO DATE
NOTICE TO APPLICANT If, after making this Certificate of CITY C-P. d TEL No
Exemption, you should'become subject to the Workers LEGAL R
Compensation provisions of the Labor code,you must forthwith DESCRIPTION LOT NO A HWY OR ST WIDENING 1
comply with"such provisions or this permit shall be deemed I
revoked _ - BLOCK TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO OF BLOCS PERMIT NO
SIZE OF LOT NOW ON LOT
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 t
effect I CONTRACTOR CONNECTION CHARGE FEE `
License Number LIC Class 11116
ADDRESS REIMBURSEMENT FEE Y O
Contractor Date DISTRICT NO GROUP MAP PROCESSED B V
' _ ' CITY TELVO I BK PG Z
❑ I am exempt under Sec of the L A CoSTATE '
P LICENSE NO CLASS i 0
Plumbing Code and/or Sec ` of the NO DESCRIPTION OF WORK FEE FINAL I V
HOUSE SEWER CONNECTING TO DATE '? VALIDAT N IL
G
B &P Code f PUBLIC SEWER the following reason SEPTIC TANK SEEPAGE PIT OR Z
' PITS AND/OR DRAINFIELD FINAL
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM )
Signature - CONNECT ADDITIONAL BLDG'OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
I hereby affirm that I am exempt from the Contractor's License XTENFLCESSPOOLGDRYWELL MANHOLE '
Law for the following reason (S_ecton 7031 5, Buisness and Pro- ALTER EPAIR R ABANDON HOUSE i)
fessions Code) SEWER SAL SYSTEM (J
I,as owner of the property or my employees with wages as
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business
and Professions Code) OWNER'S Permit $ 1u
❑ j as owner of the property am exclusively contracting with AUTHORIZATION TOTAL FEE ACCT.1r
licensed contractors to construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED`CONTRACTOR TO
�Business and PrOfe5510rIS Cade) - - CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER W�1l7 21.9-0
CONSTRUCTION LENDING AGENCY T*T
I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19— 1 1
OS
for the performance of the work for which this permit is OWNER OR
issued (Sec 3097, Civ C ) OWNERS AGENT '['('l1 AL 271 -50
` ADDRESS 21.50
Lender s Name CASH
r ■00
Lender s Address CHANGE
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, iJCC1f�1_0101 1f 6/89
and hereby authorize representatives of this County to enter '
u o the above-mentione troop rtyyffor inspection purposes .� L - 0244 1 r11'110� `
Signature of Permittee + Date ,i SEE REVERSE FOR EXPLANATORY LANGUAGE '