HomeMy Public PortalAbout4930 BALDWIN AVE_Sewer__ WORKERS COMPENSATION DECLARATION 808 (7 80)D
CE APPLICATION FOR PERMIT
CE 808
I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL
Insure or a certificate of Workers Compensation Insurance or
a certified copy thereof(Sec 3800 Lab C) COUNTY OF LOS ANGELES C BUILDING AND SAFETY
Policy No a i Company
i
ID Certified copy is hereby furnished FOR APPLICANT TO FILL IN CONNECTION DATA
BUILDIN y ADDRESS STATION �O �i DEPTH
Certified copy Is filed with the county building Inspection L L� ci
UPPE
department LOCALITY MANHOLE REFERENCE /0/5' ' -L'&Wf R
Date Applicant NEAREST TYPE OF CONN EC N LENGTH FROM
CROSS ST Y CURB P L M L TO P L
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCEP C NO
OWNER CO IMP NO , JOB NO }
MAIL IL
(This Section need not be completed if the work involved ADDRESS TRUNK PERMIT NO ROAD PERMIT NO O
by the permit is for one hundred dollars ($100) or less) 24 U
AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
CITY p TEL NO 3
I certify that in the performance of the work for which this LEGAL
permit is Issued I shall not employ any person In any manner DESCRIPTION LOT No HWY OR sl WIDENING 0
so as to become subject to the Workers Com?Z��
U
-t'j aJ /! //n BLOCK TRACT STATE ENCROACHMENT WDate Applicant 04�K/L�.0 NO OF BLD6S PERMIT NO CL
NOTICE TO APPLICANT If after making this Certificate of sizE of Lor rvow on LOT z
Exemption you should become subject to the Workers USE OFBUILDINGS CHARGES
Compensation provisions of the Labor Code you must forth
with comply with such provisions or this permit shall beCONNECTION CHARGE FEE
deemed revo Ked CONTRACTOR 1
REIMBURSEMENT FEE
LICFNSED CONTRACTORS DECLARATION ADDRESS D
DISTRICT NO GROUP MAP PROC9dSED By
I hereby affirm that I am licensed under provisions of Chapter CITYrEL No �a/ 7 BK PG
9 (commencing with Section 7000) of Division 3 of the Busl l
ness and Professions Code and my license is in full force and STATE LLIC
effect LICENSE NO ! CLASS
NO DESCRIPTION OF WORK FEE
Class HOUSE SEWER CONNECTING TO FINAL /► VALIDATION
License Number Lic Class PUBLIC SEWER DATE
SEPTIC TANK SEEPAGE PIT OR
Contractor Date
PITS AND/OR DRAINF I ELD T
FINAL
HOUSE SEWER CONNECTING TO BY
Q
I am exempt from the licensing requirements as I am a PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG OR
licensed architect or a registered professional engineer WORK TO HOUSE SEWER
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acting in my professional capacity (Section 7051 BLL$ OVERFLOW SEEPAGE PIT OR AIN FIELD
mess and Professions Code) E.TN CESSPOOL ORYWELL MANHOLE
ALTER REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
Lic or Reg No Date
HOME OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors OWNERS Permit s 3 5 9 5 A
License Law for the following reason (Section 7031 5 Busi AUTHORIZATION TOTAL FEE
ness and Professions Code) I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON # O O O O 1 0
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
I as owner of the property will do the work and the TO THE PUBLIC SEWER
structure is not intended or offered for sale (Section SIGNED THIS DAY OF 19 210 - 2250
7044 Business and Professions Code) OWNER OR
OWNERSAGENT o oro 2 2 5 0
25
CONSTRUCTION LENDING AGENCY ADOREss
I hereby affirm that there is a construction lending agency 01102-81
for the performance of the work for which this permit is -
issued (Sec 3097 Civ C)
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 Courty
ordinances and State laws regulating Plumbing and Sewers
and hereby authorize representatives of this County to enter
upon the above mentioned ro a for uispec pon purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permit ee Date