HomeMy Public PortalAbout10529 BOGUE ST_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of.consent to self
Insure, or a certificate of Workers'Compensation Insurance, or 76A6420
a certified;opX_thereof (Sec 3800, Lab C.) CE808(REV 8/81) APPLICATION FOR PERMIT'
Policy No. Company ®s
❑ 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.
Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING0 +7 STATION r � DEPTH
{COMPENSATION INSURANCE ADDRESS d'
(This section need not be completed if the work involved by the LOCALITY MANHOLE REFERENCE UPPERER
permit is for one hundred dollars ($100)or less.) LENGTH FROM
NEAREST TYPE OF CONNECTION
I certify that in the performance of the work for which this CROSS ST Y CURB L ML TO P L }
permit is issued, I shall not employ any person in any manner m.'
so as to become subject to the Workers'Compensation Laws. PC NO O
OWNER CO IMP NO JOB NO 0
Date Applicant
ADDRESS �,� OMAIL ERMIT NO ROAD PERMIT NO ' Ix
NOTICE TO APPLICANT- If, after making this Certificate of CITY TEL NO .�Q AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
Exemption, you should become subject to the WorkersLEGALU
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO 'a � HWY OR ST WIDENING
comply with such provisions or this permit shall be deemed
revoked BLOCK TRACT STATE ENCROACHMENT Z
LICENSED CONTRACTORS DECLARATION NO OF BLDGS PERMIT NOSIZE OF LOT NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter USE OF
9 (co'mmencing 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 ADDRESS REIMBURSEMENT FEE
DISTRICT NO GROUP MAP PR ESSED BY
Contractor- Date CITY TEL NO BK PG
❑ I am exempt under Sec. of the L A.Co. STATE LIC.LICENSE NO CLASS NO DESCRIPTION OF WORK FEE 7,10L�
✓
Plumbing Code and/or Sec. of the FINAL VALIDATION
HOUSE SEWER CONNECTING TO pCs DATE
B & P Code for the following reason l PUBLIC,SEWER /a
SEPTIC TANK,SEEPAGE PIT OR FINAL
PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO BY ,�-
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG OR ►
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
I hereby, affirm that I am exempt from the Contractor's License EXTNOVERFLOW
SEEPAGDRYW DRAELL,MFIELD
Law for'the'following reason (Sectan 7031.5, BUisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
feSS' ns Code): SEWER OR DISPOSAL SYSTEM -2,9.9S6 A
�LJf I,as owner of the property,or my employees with wages as #'o ° 0,0 1, 0
I
their sole compensation, will do the work and the structure '
is not intended or offered for sale (Section 7044, Business 2 °F° 2 7 5 0
and Professions Code) OWNER'S Permit $ o 50
❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE ASEWER ,�
° °Z ° 2 7 5 0
licensed COnirOC10r5 10 construct the project (Section 7044, I HAVE AT THIS DATE,A CONTRACT WITH THE HEREIN NAMED CO Z.•2 6'-84
Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLICONSTRUCTION LENDING AGENCY ,I hereby affirm that there is a construction lending agency SIGNED THISDAY OF
for the performance of the work for which this permit is OWNER OR
issued (Sec. 3097, Civ C.). OWNERS AGENT
Lender's Name " ADDRESS
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 County
ordinances and State jaws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter i
U
t e ove-menti ed property for inspection purposes
'04 -
ature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE