Loading...
HomeMy Public PortalAbout5926ALESSANDRO AVE_Sewer (2) II + ' YORKERS' COMPENSATION DECLARATION I hereby,affirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance, or 76A642D a certified copy thereof (Sec. 38001-110b C.) /� CE 808(REV.8/81) APPLICATION. FOR PERMIT Policy No. Company ��(j�„`�'�-�'ll��"" ©s F❑ Cc rtified copy is hereby furnished. SEWER - SEWAGE DISPOSAL L Certified coop filed with the county bu'lding inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY departmen Dateld-10 Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE PADRE /6 STATION S,.� f' DEPTH (This section need not be completed if the work involved by the' MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.)I certify that in the performance of the work for Which this qq 7— TYPE 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 P.c.No. so as to become subject to the Workers'Compensation Laws. 'v� CO.IMP.NO. JOB NO. TRUNK PERMIT NO. ROAD PERMIT NO. DateApplicant — AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTICE TO APPLICANT: If, after making this Certificate of IPX TEL.NO. 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 SIZE OF LOT NO.OF BLDGS. PERMIT NO.I hereby affirm that I am licensed under provisions of Chapter NOW ON LOTUSE OF ^� 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS (M/�VL /� CHARGES ness and Professions Code, and my license is in full force and ��y�q �� effect. Q CONTRACTOR kA ��1 CONNECTION CHARGE FEE 1 I� License Number/ `� O�I� J� LiC.CIaSG� � tS - oADDRESS REIMBURSEMENT FEE Contractor i�7 W ti 1 l Date lJ��V�- ! 1'39,5 DISTRICT NO. GROUP MAP PROCESSED BY CITY TEL.NO. \// gK PG ❑ I am exempt under Sec. of the L.A.Co. STATE LIC. No. CLASS 1 r O Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK q FEE FINAL HOUSE SEWER CONNECTING TO DATE VALIDATIONLM B. & P. Code for the following reason PUBLIC SEWER LM SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY e PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER I hereby affirm that I am OVERFLOW SEEPAGE PIT,DRAINFIELD exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Secton 7031.5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE 10 fessions Code): SEWER OR DISPOSAL SYSTEM ACCT.❑ !I,as owner of the property, or my employees with wages as ACi '7 their sole compensation, will do the work and the structure ° 307 (s J� is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S Permit $ 1 ITEMS ❑ 1, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE � TOTAL 27 . 50 licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELL GTO THE PUBLIC SEWER. CHECK 27.50 CONSTRUCTION LENDING AGENCY v�✓�E' �� , CHANGE .�I I hereby affirm that there is a construction lending agency SIGNED THIS jCy OF 19_ for the performance of the work for which this permit is OWNER OR OWNERS AGENT issued (Sec. 3097, Civ. C.). ADDRESS Z Lender's Name V 00_000 1 fl ;6lU Lender's Address 418 = 1 AM10,30 1 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 hereby aut ize representatives of this County to enter upon thea ove ntioned roperty for inspection pu es. l( Signa ure of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE