HomeMy Public PortalAbout5453 CLOVERLY AVE_Sewer__ WORKERS' COMPENSATION DECLARATION �j
1 hereby affirm that I have a certificate of consent to self 20-oo5T DPW 6189 u
Insure,.Or a ierhficate of Workers' Compensation Insurance, or 76A642D
a certified copy thereof (Sec 3800, Lab C ) APPLICATION FOR PERMIT
Policy No - Company
❑ 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
COMPENSATION
COMPENSATION INSURANCE ADDRESS `_� kL'^ STATION DEPTH
(This section need not be completed if the work Involved by theMANHOLE 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 S,
. Y CURB P L 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' Compensation Laws. DESCRIPTION LOT NO i C NO
I P CO IMP NO lOB NO
BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
Date Appllcont
NOTICE TO APPLICANT If, after makingthis Certificate Of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
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 _ _ Lk:iuz lai r7
9 (commencing with Section 7000) of Division 3 of the Busi- MAILs / CHARGES
ness and Professions Code, and my'license is in full force and ADDRESL -ti
effect CITY Z2 Olt TEL NO - CONNECTION CHARGE FEE
License Number Lic. Class CONTRACTOR �2(r! `� REIMBURSEMENT FEE
Contractor Date DISTRICT NO GROUP MAP PROCESSED BY
ADDRESS p �( BK PG
❑ 1 am exempt under Sec. of the L.A. Co. y�clTv TEL NO QO .J L }�c _ a
Plumbing Code and/or Sec of the STATE LICENSE NO CL SS DATE L VALIDATION Z
B 8 P Code for the following reason NO. DESCRIPTION OF WORK FEE O
HOUSE SEWER CONNECTING TO FINAL _ }-
Date PUBLIC SEWER BY (�
SEPTIC TANK SEEPAGE PIT OR -` LU
PITS AND OR DRAINFIELD a-
Signature Poo.OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING TO Z
PRIVATE DISPOSAL SYSTEM
I hereby affirm that I am exempt from the Contractor's License f CONNECT ADDITIONAL BLDG OR
Law for the following reason (Secton 7031.S, Buisness and Pro- WORK TO HOUSE SEWER
fess ns Code): OVERFLOW SEEPAGE PIT DRA)NFIELD
EXTN CESSPOOL DRYWELL MANHOLE
OS Owner of the property, or my employees with wages as ALTER REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
their sole compensation, will do the work and the structure
Is not Intended or offered for sole (Section 7044, Business
and Professions Code).
❑ 1, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Section 7044, OWNERS Permit $ 7!j
Business and Professions Code). AUTHORIZATION I TOTAL FEE
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO Poo hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER
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 information is correct I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
U e a ve-me - ned p rty fo nspection purposes.
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Signature of Permittee D SEE REVERSE FOR EXPLANATORY LANGUAGE