HomeMy Public PortalAbout8752 BURGHARDT RD_Sewer__ WORKERS'COMPENSATION DECLARATION SI
I hereby affirm that I have a certificate of consent to self 11SI
insure, or a certificate of Workers'Compensation Insurance, or /6Ae42D
a certified copy thereof (Sec 3800, Lab C) CE8DB(REV.B/Bt, 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' BUILDING @-7 �� STATION DEPTH
COMPENSATION INSURANCE ADDRESS N!
(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
I certify that in the performance of the work for which this CROSS ST. Y. CURB P.L. M.L.TO P.L.
permit is issued, I shall not employ any person in any mann O.
so as to become subject to the Workers'Com ensation Lows yJ .0 P.C.No. O
P OWNER g 1 b CO.IMP.NO. JOB NO.
_ V
MAIL l TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant FVU
ADDRESS G
AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE O
NOTICE.TO APP (CANT: If, after making this Certificate of att TEL No. U
Exemption, you should become subject to the Workers' LEGAL W
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENINGFL
comply with such provisions or this permit shall be deemed H
revoked. BLOCK TRACT STATE ENCROACHMENT z
LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT N
SIZE OF LOT NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter USE 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 Number1. LiC.Class ADDRESS REIMBURSEMENT FEE
'1
DISTRICT NO
Contractor /f Z&T Date -7/ Q 'ELLIC). y . GROUP MAP PR CESSED BY
BK PG
❑ I am exempt under Sec. of the L.A. Co. STATE uc j
P LICENSE NO. CLASS
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL q
HOUSE SEWER CONNECTING TO DATE / `�O/ VALIDATION
B. 8 P. Cade for the following reason PUBLIC SEWER A" i i
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD FINAL
Dote HOUSE SEWER CONNECTING TO BY �J
J PRIVATE DISPOSAL SYSTEM
Sgaat E/ .f CONNECT ADDITIONAL BLDG.OR ►
'OWNff-I3yILftRE ETECLARATIOK�— 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 fallowing reason (Secton 7031.5, Buisness and Pro- ALTER REPAIR OR ABANDON HOUSE <9 7 6.6 A
fessions Code): SEWER OR DISPOSAL SYSTEM
❑ 1, as owner of the property,or my employees with wages as # c'o 0 0,1 0
their sole compensation, will do the work and the structure
is not intended ar offered for sale (Section 7044, Business I o'0 2 7.5 0
and Professions Code). OWNERS Permit $ /0 0 0 0 - 2750'
❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO 0 3 1 b-8 4
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE P ' SEWER.
CONSTRUCTION LENDING AGENCY ,
hereby affirm that there is d construction lending agency SIGNED THISYOF 1
for the performance of the work for which this permit is OWNEROR g
OWNERS AGENT
issued (Sec. 3097, Civ. C.).
ADDRESS
Lender's Name -
Lender's Address �/ ��V , ✓//`t'��Z�/
1 certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordino s and State laws regulating Plumbing and Sewers,
and by outhori representafves of this County to enter
upon t above-men io d prop rty for i7nspect/ion purpose .
Signal of ermlit a Date SEE REVERSE FOR EXPLANATORY LANGUAGE