HomeMy Public PortalAbout9451 BLACKLEY ST_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self `
Insure, W o certificate of Workers'Compensation Insurance, or 76A6420
r,rm►rified copy thereof (Sec 3800, LC > // 920002 DPW 6/88
CompaAPPLICATION FOR, PERMIT
olic o ny �"L�U Ste_ - ...
Certified copy Is hereby furnished SEWER SEWAGE DISPOSAL
❑ Certified copy Is filed with the county building Inspect) COUNTY OF LOS ANGELES BUILDING ANDrSAFETY
A
department ^• "
Date--L31.-'70 Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS BUILDING
COMPENSATION INSURANCE ADDRESS STATION 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 ) LOCALITY LOWER
NEAREST TYPE OF CONNECTION LENGTH FROM -
11 certify that In the performance of the work for which this CROSS ST U Y CURB P L �M L TOP L
permit Is Issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws OWNER CO IMP NO JOB NO
` MAILTRUNK PERMIT NO ROAD PERMIT NO
Date Applicant ADDRESS
NOTICE TO APPLICANT If, after making this Certificate Of CITY CI TEL NO AFFIDAVITS WAIVER EASEMENT RECORD INSTR NO DATE
Exemption, you should` become,subject to the Workers' LECA e ,c
Compensation provisions-of the Labor code, you must forthwith DESCRIPTION LOTN HWY OR ST WIDENING y y
comply with such provisions or this permit shall be deemed
revoked BLOCK TRACT STATE ENCROACHMENT `
LICENSED CONTRACTORS DECLARATION. NO OF BLDGS PERMIT NO i
SIZE OF LOT NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter USE OF L
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 Llc Class ADDRESS (,f7 e`l ZVSCt REIMBURSEMENT FEE 8
Contractor 40 Cj t 2l,Vate CITY �j TEL NO 2 DISTRICT NO GROUP MAP PROCESSED By Z0
'1 �j BK PG
❑ I am exempt under Sec of the L A Co STATE
NO' CLASS c/� Of
f-3NO DESCRIPTION OF WORK FEE L1J
of the
Plumbing Code and/or Sec FINAL VALIDATION
HOUSE SEWER CONNECTING TO DATE
B 8 P Code for the following reason PEPTIC SEWER
SEPTIC TANK SEEPAGE PIT OR FINAL +
PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO ' BY
PRIVATE DISPOSAL SYSTEM `
Signature < CTADDITIONAL BLDG OR
OWNER-BUILDER DECLARATION 0 HOUSE SEWER
3
I hereby affirm that I am exempt from the Contractor's License OVERFLOW SEEPAGE PIT,DRAINFIELDEXTN CESSPOOL DRYWELL MANHOLE ill
Low for the following reason (Secton 7031 5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE d
fessions Code) SEWER OR DISPOSAL SYSTEM l�
- 4 �CT.
e8
❑ 1,as owner of the property,or my employees with wages as
their sole compensation, will do the work and the structure , J4e�Cl
is not Intended or offered for sales(Section 7044, Business d Permit $ ITEMS
and Professions Code) OWNER'S
❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION I TOTAL FEE TOTAL 3.4® 50
licensed Contractors to construct the project (Section 7044, r 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED -e
Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC L_HEC K -4- .50
CONSTRUCTION LENDING AGENCY CHANGE
�
I hereby affirm that there Is a construction lending agency SIGNED THISCHANG
_DAY OF 19 (1 E i f
1
for the'performance of the work for which this permit Is OWNER OR
Issued (Sec 3097, Civ C ) OWNERS AGENT
ADDRESS
Lender's Name IV -IJVIJ { {�+I
{
Lender's Address ' 105 1 Aa7o(t f
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 lows regulating Plumbing and Sewers, ,
and hereby authorize representatives of this County to enter
upon th�bove-�efione%ope�,Iyor Inspection purposes • �
— s
V
Sign m
ture of Perltl Date SEE REVERSE FOR EXPLANATORY LANGUAGE