HomeMy Public PortalAbout6002 CLOVERLY AVE_Sewer__ WORKERS'COMPENSATION DECLARATION / ` s
I hereby affirm that I have a certificate of consent to self �1
insure, or a certificate of Workers'Compensation Insurance, or 76A642D U
a tif' dt p th rVfz(Se5.,n
p y 00L.b' )_ �- `E808`REV."e" APPLICATION FOR PERMIT
Com
ElCertified 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' [7_
^ STATION �r f 7�—�.�yr DEPTH
COMPENSATION INSURANCE / �%� Cv
(This section need not be completed if the work involved by the + MANHOLE REFERENCE ^� cc UPPER
permit is for one hundred dollars ($100)or less.) /fLrG J L
AREST TYPE OF CONNECTION LENGTH FROM
I.certify that in the performance of the work for which this O55 ST. C U V. CURB P.L. M.L.TO P.L.
permit is issued, I shall not employ any person in any manner ?
so as to become subject to the Workers' Compensation Laws. OWNER [20 P L P�� CO.IMP.NO. 3/F JOB NO.
MAIL A TRUNK PERMIT NO. ROAD PERMIT NO. � ��
Date Applicant ADDRESS !r4
NOTICE TO APPLICANT: If, after makingthis Certificate Of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
CITU � TEL.NO. "��°
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING • ���n
comply with such provisions or this permit shall be deemed W
revoked. BLOCK TRACT STATE ENCROACHMENT
NO.OF BLDGS. PERMIT N .
LICENSED CONTRACTORS DECLARATION SIZE OF LOT NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter USE of /S r'
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. �"�,i CONTRACTOR ip Lo M 11 CONNECTION CHARGE FEE
License Number S VpIO �`g'�/„L,ic.Class � ADDRESS n �"�,� REIMBURSEMENT FEE
Car'
tractor e`er / YYUaie CITY ��j� TEL NO. G�®� i J DISTRICT NO. GROUP MAP - PR ESSED BY
BK PG 0
❑ t under Sec. othe L.A.CO. STATE s CL C
I am exem df hC �z 99
P LICENSE NO. � CLASS C--3(1-1
DESCRIPTION OF WORK FEE
Plumbing Code and/or Sec. of the NO. FINAL
HOUSE SEWER CONNECTING TO DATE VALIDATION
B. & P. Code for the following reason PUBLIC SEWER 3 �—Z
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD FINAL 4y
ate HOUSE SEWER CONNECTING TO BY �-
PRIVATE DISPOSAL SYSTEM
SignatureE - CONNECT ADDITIONAL BLDG.OR 1111111.W ILDER D I N WORK TO HOUSE SEWER ,
OVERFLOW SEEPAGE PIT,DRAINFIELD
I hereby affirm that I am exempt Mom the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE
Law for the following reason (Se On 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE O O CT`y A
fessions Code): SEWER OR DISPOSAL SYSTEM
❑ I,as owner of the property,or my employees with wages as 11, 0,° ° ° 1 0
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business 12'-'0.2 T5 0
and Professions Code). OWNER'S Permit $
AUTHORIZATION1-.-Ji-.2 7. 5 C 6
❑ I,as owner of the property,am exclusively contracting with TOTAL FEE ,50 .0
licensed COn1raC10r5 f0 construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO O S,2 8-84
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY ,
I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_
for the performance of the work for which this permit is OWNER OR
issued (Sec. 3097, Civ. C.). OWNERS AGENT
ADDRESS
Lender's Name
Lender's 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 PI bing and Sewers,
and hereby out rize represe otives of his County to enter
Pon the abo -mentioned pr erty r nspection purposes.
Ignoture of Permittee / - Date SEE REVERSE FOR EXPLANATORY LANGUAGE