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HomeMy Public PortalAbout5926ALESSANDRO AVE_Sewer r WORKERS'COMPENSAZION DECLARATOR! • w affirm that I-have a certificate of consent to self Visure,-or a certificate of Workers'Compensation Insurance, or 76A642D a certVied copy thereof (Sec. 3800, Lab C. CE 808(REV.8/81) Policy No. Company ©s APPLICATION FOR PERMIT J Certified copy is hereby furnished. SEWER - 'SEWAGE DISPOSAL LR-Certifiecl copy is filed with the county building inspe tion COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Date _ V Vpplicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' FG -,,? STATION DEPTH COMPENSATION INSURANCE �This section need not be com leted if the work involved b the UPPER ( p y MANHOLE REFERENCE LOWER permit is for one hundred dollars ($100)or less.)I certify that in the performance of the work for which thisNEARETYPE OF CONNECTION LENGTH FROM Y. - CURB P.L. M.L.TO P.L. permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. P.C. NO. I P OWNER Cj CO.IMP.NO. JOB NO. MAIL Date Applicant ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO. NOTICE TO APPLICANT: If, after making this Certificate of CIT EL.NAFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATEo Exemption, you should become subject to the Workers' LEGAL 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. BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. 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- BUiIDINGS CHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTOR CONNECTION CHARGE FEE License Number 20 76 / Lic.Class Z 0 /J�� � Q ADDRESS REIMBURSEMENT FEE COntractory(ic./ Date CITY TEL.NO. �� 3 DISTRICT NO. GROUP MAP MAP PROCESSED BY g PG ❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. Zo 7 I STATE LIC 2— �t og ✓ LA21 K �SGi anss C a� �9 Plumbing Code and/or Sec. of The NO. DESCRIPTION OF WORK FEE FINAL VALIDATION HOUSE SEWER CONNECTING TO 111A DATE B. & P. Code for the following reason PUBLIC SEWER [11r—JSEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD FINAL e Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR ► OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE io Law for the following reason (Sectors 7031.5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE 1 fessions Cade): SEWER OR DISPOSAL SYSTEM • ACCT.* ❑ I,as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure 307 61.50 is not intended or offered for sale (Section 7044, Business Permit $ '- .. ' ITEMS and Professions Code). OWNERS AUTHORIZATION OTAL 610 .5O ❑ I, as owner of the property, am exclusively contracting with TOTAL FEE �• •' ��--- T� licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONT ACTOR TO CHECK Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. 1. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_ , CHANGE •(X{ for the performance of the work for which this permit is OWNER OR OWNERS AGENT issued (Sec. 3097, Civ. C.). ADDRESS 7�� �— �i / Q Lender's Name Lender's Address 3749 1 AM10:3 I certify that I have read this application and state that the r 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 County to enter upon the above-mentioned grope y for inspectction purposes. L/C W) /\ � Z— Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE