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HomeMy Public PortalAbout5922 BURTON AVE_Sewer__ WORKERS' COMPENSATION DECLARATION ! y' I,Jhereby't:�F',irm that I hove a certificate of consent to self 20.0051 DPW 6189 u Insure`, a, cehif cC BR f Workers' Compensatio Insurance, or ]6A642D certified cop, thereof (Sec. 3800, Lab C. APPLICATION FOR PERMIT Policy I A Company . ❑ Certified copy is hereby f ished SEWER - SEWAGE DISPOSAL ❑ Certified copy is fit with the county building inspection COUNTY OF LOS ANGELES BUILDING,AND SAFETY department: ' Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CE IF KATE OF EXEMPTION FROM WORKERS' DRILLING COMPENSATION INSURANCE ADDRESS STATION oEPTH (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 MANHOLE NEAREST TYPE OF CONNECTION LENGIH FROM certify thOPln the performance of the work for which this CROSS ST, Y CURB PL Mt TOPL permit is issued, I shall not employ any person in a rte LEGAL - s0 as to be Pate subject to the Workers C Ion law DescRtanory LOT No. Co IMP No LOB rNia 9 BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO Date / pplicant ASSESSOR AFFlDAVIT wANER EASEMENT RECORD INSTR NO DATE NOTICE TO APPLICANT: If, of er making this Certificate of MAp BOOK PAGE RARCEL Exemplon; you should become subject to the Workers' NO.OF BLOCS. Compensationprovisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT HWY OR Si wIDFNING comply with such provisions or this permit shall be deemed USE OF revoked. BUILDINGS STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION PERMIT No I hereby affirm that 1 am licensed under provisions of Chapter OWNER 9 (commencing with Section 7000) of Division 3 of the Busi- MAILADDRESSV � r � A/ CHARGES it Hess and Professions Code, and mylicense is In full force and effect CONNECTION CHARGE FEE GItY license Nam be, Ic.Class 43 RUMBuaSEMENT FEE yD —7 —9 CONTRACTOR 1 w, w COnllada! IL1 WO are DISTRICT NO GROUP MAP �' PROCESSED BY DDREI BI ❑ I am exempt under Sec. of the L.A.Co. O Z vvi/'v 0 -3 — p; Cli - TEL.NO. D "_ _ . © Plumbing Code and/or Sec. Of the STATE Lc. /� FINAL r U Ik. , LICENSE No. �`� �. CLAss lam' DATE T/_Z� ,V,ALIDATION ' , ,j�eZ t B. 8 P. Code far the fallgwl a On NO. DESCRIPTION OF WORK FEE Y p HOUSE SEWER CONNECTING TOFINAL "Vd'y[i .fv Dote PUBLIC SEWER By - ttv'�_ SEPTIC TANK SEEPAGE PIT OR W Signature PITSAND OR DRAWFIELD r N g HOUSE SEWER CONNECTING TO _ rZ OWNER-BUILDER DECLARATION PRIVATE DISPOSAL SYSTEMUy ytkl[grtf I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR %�/5 7z- -El L __ WORK t0 MOUSE SEWER -{Lt, 3If !I I Low for the following reason (Secton 7031.5, Bulsness and Pro- _ Etl t 4 f¢SSiOnS Code): OVERFLOW SEEPAGE Pit,DRAINFIELD �'^ ❑ fxTN,CESSPOOL. BANDO,MANHOLE as Owner Of the property,or my employees with wages as ALTER,REPAIR OR ANHOUSE ER OR their sole compensation, will do the work and the structure SEWDISPOSAL SYSTEM is not intended or offered for sale (Section 7044, Business and Professions Code). ❑ I,as owner Of the property, am exclusively contracting with OWNER'S Permit $ ,) licensed contractors to construct the project (Section 7044, Business and Professions Code). AUTHORIZATION TOTAL FEE CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HERON NAMED CONTRACTOR To I hereby affirm that there is a construction lending agency CONNECT RIEABOVE DACPIEED EXISTING DWELLI NO TO THE PUBLIC F&WER for the performance of the work for which this permit is - - issued (Sec. 3097, Civ- C-). SIGNED THIS DAY OF 19_ OWNER OR Lender's Name OWNERS AGENT Lender's Address ADDRESS I certify that I have read this application and state that the above inforrnoll.n is Correct. I agree to comply with all County - ordinances and State la s IOting Plumbing and Sewers, and hereby mi - r r Ives of this County to enter upon the above- ntioned prop ty for inspection purpoRses. Signa Nre of Permittee D to SEE REVERSE FOR EXPLANATORY LANGUAGE