HomeMy Public PortalAbout10822 DAINES DR_Sewer__ WORKERS' COMPENSATION DECLARATION 20 W51 �F I
1 hereby affirm That I have o certificate of consent to self 76A642D
DPW 6109 U
,,,insure, or a certificate Of Workers' Compensation Insurance, or 6A642
a certified copy thereof (Sec,.3800, Lab C.) APPLICATION
FOR
PERMIT Policy No. Company I�I�II'd��Hv tlu
❑ Certified copy is hereby furnished SEWER - SEWAGE DISPOSAL
Ll Certified copy is filed with The county building inspection COUNTY OF LOS ANGELES , BUILDING AND SAFETY
department.
Date Apphmnt FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BImDING yl� Q _ /� STATION
COMPENSATION INSURANCE ADDREBS l/ t/ Y
(This section need not be completed if the work involved by the ,El /> - .MANHOLE REFERENCE UPPER
permit is.for one hundred dollars ($100)or less.) NEA LOCALITY C•,PLC (�/ Lowen
NEAREST j TYPE OF CONNECTION LENGTH FROM
I certify that in The performance of The work lo which ,his GROSS ST. L V CURB Pt Mt LOFT
permit is issued, I shall not employ ny person in y manner LEGAL PC NO
so as to become subject to the W , r Comp a Ion Laws. DESCRIPTION LOT N0. co IMP NO Joe No
BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
y Dale Appllcon
ASSESSOR AFFIDAVIT I WAIVER E45EMENi RECORD INStR NO DATE
NOTICE 70 APPLI ANT: If, offer making this Certificate of NAP 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 HWv OR ST WIDENING
comply with such provisions or This permit shall be deemed USE OF
revoked. BUILDINGS STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION �/��FF /�. ',�L PERMIT NO
I hereby affirm that I am licensed under,provisions of Chapter OwNER1-L1` 4'41f1-L� /�{ 1/'f I L(}
9 (commencing with Section 7000 of Division 3 of the Busi- MAIL p �,s i� LZ
ness and Professions Code, and my license is in full force and AODRE—ss �L,.O d)=V (i�F�E— �f �A/ CHARGES
effect. CITY / c."' 1 It eI F ET L NO. Q I V ✓(� CONNECTION CHARGE FEE
License Number Lic.Class REIMBURSEMENT FEE
CONTRACTOR
Contractor Dote DISTRICT NO GROUP MAP PROCESSED BY
p ADDRESS �� BK RG }
❑ am exempt under Sec. of The 1.A.Co. crry TELNO. 4
Plumbing Code and/or Sec. ofthe STATE OC. FINAL V
LICENSE NO. CLASS DATE !� VALIDATION o
B. 8 P, Code for the following reason NO. DESCRIPTION OF WORK FEE
HOUSE SEWEP CONNECTING TO FINAL F
Date PUBLIC SE'NER BY 8
SEPTIC TANK SEEPAGE Air OR W
a
Signature PITS AND p4 DRPAGE ID UU
OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING TO D z
PRIVATE DISPOSAL SYSTEM
I hereby affirm That I am exempt from the Contractor's license CONNECT ADDITIONAL BLDG OR y)
Law for the following reason (Secton 7031.5, Buisness and Pro- WORK TO HOUSE SEWER
fessi Ons Code): OVEIRFLOW SEEPAGE PIT,
YWEu AINFEUD LE L. Y
LI'�I LIC:
C I, as owner of the property, or my employees with wages as AItER. FP OR ABANDON HOUSE ..._ _ _� -C
/C SEWER ISP05AL SYSTEM '.?.1 L• a+• T
their sole compensation, will do the work and the structure - -' - __
is not intended or offered for sale (Section 704j(4, Business EM,,-,
ssions
and ProfeCode). _ �L
I, as owner of the property, am exclusively contracting with ��FF I I AL c m - '�—°
licensed Contractors to construct the project (Section 7044, OWNER'S I Permit $ CHECK ea .JCT
Business and Professions Code). AUTHORIZATION TOTAL FEE C
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TOCHAi�L�I D .01-iI hereby affirm that there is O Construction lending agency CONNECT THE ABOVE DESCRIBED EKISTING 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_ t
/5'
OwNFR OR It�i[li 2 r/ U
Lender's Name OWNERS AGENT { ..1�I112�1Y
Lender's Address ADDRESS V 154 . AMIDI-1
I certify Thai I hove read this application and slate That the
above information is correct. I agree to comply with of County -
ordinances and State lows regulating Plumbing and Sewers,
and hereb autppr property t of this County to enter
this County p enter _
upo th ave-m n d property for inspection purposes.
Signature of ern ee Date SEE REVERSE FOR EXPLANATORY LANGUAGE