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HomeMy Public PortalAbout4927 CLOVERLY AVE_Sewer__ WORKERS' COMPENSATION DECLARATION b heteby`offirm that I have a certificate of consent to self 20-0051 DPW 6189 insure, or a certificate of Workers' Compensation Insurance, or 76A642D a certified y�apaSec3800 Lab C. APPLICATION FOR PERMIT Policy No. El Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL Certified copy is filed with f ty building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY d4*� Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXE ON FROM WORKERS' BUILDING COMPENSATION INSURANCE ADDRESS STATION27 `/j, DEPTH (This section need not be completed if the work involved by the LOCALITY MANHOLE REFERENCE `J C7' p[� L WER permit is for one hundred dollars ($100)or less.) I certifythat in the performance Of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROM P CROSS ST. _ Y CURB PL M L TO P L permit is issued, "I shall not employ any person in any manner LEGAL so as to become subject to the Workers' Com ensation Laws. DESCRIPTION LOT No. PC NO I p CO IMP NO JOB NO Date Applicant BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO NOTICE TO APPLICANT: If, after makin this Certificate of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE g MAP BOOK PAGE PARCEL Exemption, you should become subject to the Workers' NO.OF BLDGS. Compensation provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT HWY OR ST WIDENING 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 I am licensed under provisions of Chapter OWNER 9 (commencing with Section 7000) of Division 3 of the Busi- MAIL CHARGES ness and Professions Code, and my license is in full force and ADDRESS effect. ...'`}yyy�{���`,��(///����Q�g CITY TEL.NO. CONNECTION CHARGE FEE License NumberdL�_Lic. Class�\B REIMBURSEMENT FEE CONTRACTOR Contractor ate i ckz/ DISTRICT NO GROUP MAP PROCESSED BY T ADDRESS ❑ 1 am exempt under Sec. of the L.A. Co. CIT ✓°' TEL NO. —Al a Plumbing Code and/or Sec. of rhe STATE LIC. (� FINAL V LICENSE NO. CLASS-'V✓ DATE (� /� VALIDATION z B. 8 P. Code for the following reason NO. DESCRIPTION OF WORK FEE 7y—7 —4 Z O HOUSE SEWER CONNECTING TO FINAL h Date PUBLIC SEWER BYW (� SEPTIC TANK SEEPAGE PIT OR Q. Signature PITS AND OR DRAINFIELD HOUSE SEWER CONNECTING TO OWNER-BUILDER DECLARATION PRIVATE DISPOSAL SYSTEM Z I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR Law for the following reason (Secton 7031.5, Buisness and Pro- WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT, DRAINFIELDE fessions Code): EXTN.CESSPOOL. DRYWELL.MANHOLE ❑ I, as owner of the property, or my employees with wages as ALTER, REPAIR OR ABANDON HOUSE their sole compensation, will do the work and the structure SEWER OR DISPOSAL SYSTEM..,� ,_, is not intended or offered for sale (Section 7044, Business 33 1 66.573 and Professions Code). ❑ I, as owner of the property, am exclusively contracting with 1 1 T licensed contractors to Construct the project (Section 7044, OWNERS Permit $ TOTAL 66. 53 Business and Professions Code). AUTHORIZATION I TOTAL FEE _ CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR To f" t,.''HE I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRI ED EXISTING DWELLING TO THE PUBLIC SEWER CHANGE _ for the performance of the work for which this permit is 010 /,61r't��E1 p/ issued (Sec. 3097, Civ. C.). SIGNED THIS DAY OF e.+e�tib-`-- 19•, OWNER OR Lender's Name OWNERS AGENTADDRESS AW- 6356 101'131 11 _ .N� W- J IJ Lender's Address © v c6 1 FirI ; I certify that I have read this application and state that the - above information is correct. I agree to comply with all County ordinancesan tate laws regulating Plumbing and Sewers, a hereb a h ize representatives of this County to enter pon the ntioned property for inspection pytposes. /a6-g Signa ure of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE