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Home My Public Portal AboutUntitled WORKERS'COMPENSATION DECLARATION ) 2 DPW 92-000 3/87 I hereby affirm that 1 have a certificate of consent to self �--;�.-- i ' •" ;nsu:e, or•a certificate of Workers'Compensation Insurance,or CE 802D u a certified copy thereof (Sec. 3800, Lab C.) �E 808APPLICATION FOR PERMIT Policy No._.----- ^,,_Company 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. Dote _Applicant i FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BU A DDRESS , '• - 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.) - - LENGTH FROM 1 certif that in the erformance of the work for which this TYPE of coNNEaIONY p permit is issued, I shall not employ any person in any manner -_--- Y. cuRe P.L. M L To P.L. P.C.NO. 50 a5 to become subject to the Workers'Compensation LOWS. - � CO.IMP.NO. JOB NOc TRUNK PERMIT NO. ROAD PERMIT NO. DateApplicant - J - – AFFICAViT WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTICE TO APPLICANT: If, after making this Certificate of 'r NO.Exemption, you should become subject to the Workers'Compensation provisions of the Labor code, you must forthwith ION LOT NO. HWV.OR ST.WIDENING comply with such provisions or this permit shall be deemed -- revoked. BLOCK TRACT -- --- ENCROACHMENT 7—� LICENSED CONTRACTORS DECLARATION N .Of BLDGS. PERMIT NO. I hereby affirm that I am licensed under provisions of Chapter SIZE OF LOT NOW ON LOTUSE 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 I ADDRESS REIMBURSEMENT FEE 4 Contractor Date y i — DISTRICT NO. GROUP MAP PROCESSED BY (� i' BK PG Z ❑ I am exempt under Sec. of the L.A.Co. LICENSE NO.TE t" LIC, O SS 'WORK FEE U Plumbing Code and/or Sec. of the NO. DESCRIPTION OF FINAL VALIDATION w HOUSE SEWER CONNECTING TO DATE B. $ P. Code for the following reason PUBLIC SEWER r� G�'_. Z N SEPTIC TANK,SEEPAGE PIT OR FINAL Z PITS AND/OR DR,AINFIELD 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 - Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM ❑ 1,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 $ " O'l, as owner of the property, am exclusively contracting with AUTHORIZATION I TOTAL FEE [ licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONT ACTOR TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING.DWELLING TO THE PUBLIC SEWER. - - CONSTRUCTION LENDING AGENCY Pilo hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_ for the performance of the work for which this permit is OWNER OR issued (Sec. 3097, Civ. C.). OWNERS AGENT • -- ADDRESS _ .. .._ Lender's Name _. Lender's Address r I certify that I have read this application and state that the r above information is correct. I agree to comply with all County f G Ordinances and State laws regulating Plumbing and Sew ers, �P and hereby authorize representatives of this County to enter upon the above-mentioned property: r inspection purposes. r .. P P. P Y dtT � a Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE