HomeMy Public PortalAbout8766 BURGHARDT RD_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consentto self
insure, or'a certificate of Workers'Compensation Insurance, or 76A6<20
a certified copy thereof (Sec. 3800, Lob C. .CE BOB(REV.8/81)
APPLICATIONPolicy No. Company FOR
PERMIT
❑.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.
Dole Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' euuDING ['
COMPENSATION INSURANCE ADDRESSee-a ZAK UPPER
STATION DEPTH
(This section need not be completed if the work involved by the f MANHOLE REFERENCE LowfR
permit is for one hundred dollars ($100),Or lessr) LOCALITY
I certify that In the'performance of the wOfk for which this NEAREST, TYPE OF CONNECTION LENGTH FROM
CROSS ST. Y. CURB P.L. M.l.iOP.I.
permit is issued, shall not employ Ony person in any mggn net 11 P.C.NO,
so as to become subject to the Workers' Compensation L B. OWNER CO IMP.No. JOB NO. O
-7/ MAIL {�
..�� ���� pp��� p /� TRUNK PERMIT NO. ROAD PERMIT NO. �r
Date�_�C��Applicant* (` JC (,l}n ADDRESS'f
AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO, DATE O
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL No, U
Exemption, you should become subject the Workers' LEGAL W
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY,OR ST.WIDENING d
comply with such provisions or this permit shall be deemed N
revoked. - BLOCK TRACT STATE ENCROACHMENT Z
LICENSED CONTRACTORS DECLARATION NO OF BLDGS, PERMIT No.
SIZE OF LOT Now ON LOT
I hereby affirm that I am licensed under provisions of Chapter - USE OF - - xr, C
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. Z CONTRACTOR. CONNECTION CHARGE FEE
License NumberI/L16o3'�V Lic. Class ADDRESS a �,//J�] / ^� REIMBURSEMENT FEE
Controctor�E (- &Ae Dole ^I CITY O R/F/'J'(� ?3 3 DISTRICT NO. GROUP MAP PR ESSED BY
EL NO
STATE �A .' 9 �/ P 2 BK PG
El am exempt under Sec. - of the L.A.Co. - LICENSE No. a CLLICASS — C�� YA�1 J
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL ^
HOUSESEWERCONNECTING TO DATE y VALIDATION.
B. 8 P. Code f the following reason PUBLIC SEWER 3'� •( •. �'
SEPTIC TANK,SEEPAGE PIT OR FINAL
PITS AND/OR DRAICONNECTING
Date HOUSE SEWER CONNECTING i0 BY
PRIVATE DISPOSAL BYBifM V
Signa}Ure_ CONNECT ADDITIONAL BLDG.OR D L'
NE -BU D DECLARATION WORK TO HOUSE SEWER -
I hereby affirm that I
re OVERFLOW SEEPAGf-PIT,GRAINFIELD
empt 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
❑ I,as owner of the property,or my employees with wages as z 9 7 7 A
"their sole compensation, will do the work and the structure - - O
is not intended or offered for,sole (Section 7044, Business
and Professions Code). OWNER'S Permit $ n S'O .
❑ I, as owner of the property,Out exclusively contracting with AUTHORIZATION TOTAL FEE 2 7.5 0
licensed COntra ClOrS to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH.THE HEREIN NAMED CONTRACTOR TO it"s O =
Business and Professions Code). CONNECT THE ABOVE Df RIBED EXISTING DWELLING TO THE PUBLIC SEWER. 27 5
E
CONSTRUCTION LENDING AGENCY P - b_8'Q
I hereby affirm that there is a Construction lending agency SIGNED THIS 'DAY -// _I9�
for the performance of .the work for which this permit is .OWNER ORGENT -
OWNERS A _
issued (Sec 3097, Civ. C.). ADDRESS
Lender's Name !/
Lender's Address DTICL/V .w
I certify that I have read this application and state that the - -
above i Orion is correct 1 agree to comply with all County f -�//����
ordina a and State laws regulating Plumbing and Sewers, - ����"'�� -
and r authorize re _ ntatives of Ihis County Ib enter -
s�u(p'o-n t bove-m tion � perry or inspection purposes.
�Ig natur Af P� mittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE