HomeMy Public PortalAbout6006 CLOVERLY AVE_Sewer__ VVORKERS' COMPENSATION DECLARATION
hereby affirm that I have a certificate of consent to self
sur, ,sgr'o certificate of,Wprkers'Compensation Insurance, or 76A642D 'I
'` ,- CE 806iREV.1/831 APPLICATION FOR PERMIT u
a c rtrfc�teof 3800, La � y �
' . rt any SEWER - SEWAGE DISPOSAL
❑ C 'tified copy is hereby furnished.
Certified copy is filed with the county building ins ction COUNTY OF LOS ANGELES BUILDING AND SAFETY
de artment.
Da icant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTI CATE OF EXEMPTION FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDRESS TA TION y9 ' DEPTH
(This section need not be completed if the work involved by the , MANHOLE REFERENCE 7a� ,6 ` UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY
NEAREST - TYPE OF CON N LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. Y. 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 LOWS. OWNER CO.IMP.NO. JOB NO.
MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS
AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
NOTICE TO APPLICANT: If, after making this Certificate of CITY 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 `
comply with such provisions or this permit shall be deemed V
revoked. BLOCK TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO.
SIZE OF LOT NOW ON LOT • Z Q
I hereby affirm that I am licensed under provisions of Chapter USE of
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. CONTRACTOR CONNECTION CHARGE FEE� i
Lice a unf�e Lic.Class C ADDRESS. ��G..J REIMBURSEMENT FEE
COn_/ /r e DISTRICT No. GROUP MAP PROC SED BY
BK PG
❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. e class _ �„J v �� 'S
Plumbing Code and/or Sec. of the No. DESCRI 10 OF WOR FEE FINAL
HOUSE SEWER CONNECTING TO DATE _ (,/, VALIDA106N MM
B. 6 P. Code for the following reason PUBLIC SEWER
SEPTIC TANK,SEEPAGE PIT OR NAL
Date PITS AND/OR DRAINFIELD FINAL
HOUSE SEWER CONNECTING TO BY 6
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK To HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD
I hereby affirm that I am exempt 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
❑ 1;as owner of the property,or my employees with wages as 4 7 A
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permit S # 0.0 0 ® 1 0
❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE
licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO ' O O �' O
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
o,0 027,5
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_ , p
for the performance of the work for which this permit is OWNER Q S 2 S�
A 8 6
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 Plum'Ing and Sewers,
and hereby authorize representative of t s County to enter
u •n t ave-mentioned prop Ity or in ection purposes.
Signature of rmiitee Date ��/ SEE REVERSE FOR EXPLANATORY LANGUAGE