HomeMy Public PortalAbout5114 DOREEN AVE_Sewer__ P
' WORKERS' COMPENSATION DECLARATION
•'1,hereby affirm that I have a certificate of consent t self
• insure, or a certificate of Workerskompensation Insurance, or 92-=D /1
a c tified co thereof Sec. 380D, Lab C. z-ooaz DPW arae
P61 No. Company -
El Certified copy is hereby furnished. . SEWER SEWAGE DISPOSAL � -
❑ certified copy is filet) 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' ewInING ��� / �/� STATION DEPTH
COMPENSATION INSURANCE ADDRESS �/ /f/Y yr
(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
I certifythat in the performance of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROM
P CROSS Si. V. CURB PA. 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 �Z?45 J5/ Y. P.C.NO.
(/V L(i CO.IMP.NO. JOB NO.
/y; MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
14
Date=�lz Z- G APPlicaal% '� - �` %v ADDRESS , ,fT S•e� q 6AIWr -_QQ �(� A1C ..
NOTICE TO APPLICANT: If, after making this Certificate of CITYy/- AFFIDAVIT WAIVER EASEMENT RECORD;INSiR.NO. DATE
Exemption, you should become subject to the Workers' LOA
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO.
HWY.OR Si.WIDENING + +
comply with such provisions or this permit shall be deemed _
revoked. BLOCK TRACT 2 STATE ENCROACHMENT
•LICENSED CONTRACTORS DECLARATION .OP LOT. PERMIT NO.-
I hereby affirm that I ora licensed under provisions of Chapter USESIZOF Lor tx(/ NOW ON LOT.
(commencing ) USE DI !� `/".-.— CHARGES
9 commenof with Section 7000 of Division 3 of the Basi- euRolNGs CJ! c?�
ness and Professions Code, and my license is in full force and � (5`u
effect. CONTRACTOR lLD-e CONNECTION CHARGE FEE
License Number Llc.Class ADDRESS REIMBURSEMENT FEE
Contractor Date DISTRICT NO. GROUP BK AMP PG PR( BY O
CITY TEL NO. _ J OC/ /f� _
❑ I am exempt under Sec. of the L.A.Co. STATE - LIC. 5 �/j K
P LICENSE NO. CLASS W
F4
Plumbing Code and/or Sac. of the NO. DESCRIPTION OF WORK REHOUSE SEWER CONNECTING TO DA EL VALIDA ONM
B. 8 P. Code for the following reason PUBLIC SEWER Z
SEPTIC TANK.SEEPAGE PIT OR FINAL 1
Date
PITS AND/OR DRAINFIELD /
BY
HOUSE SEWER CONNECTING TO '
PRIVATE DISIGSAL SYSTEM '
Signature CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER D
I hereby affirm that OVERFLOW SEEPAGE PIT,DRAINFIELD am exempt from the Contractor's License EXTN..CESSPOOL,DRYWELL,MANHOLE - iA
Law for the following reason (Secton 7031.5, Bulsness and Pro- &ER,REPAIR OR ABANDON HOUSE 1V
fessions Cade): - SEWER OR DISPOSAL SYSTEM
- ACGT..
C31,as owner of the property,or my employees with wages as `17,QI
their sole compensation, will do the work and the structure 3307
is not intended or offered for sole (Section 7044, Business permit S 1 ITEM:!
and Professions Code). OWNER'S
❑ I, as owner of the property,am exclusively contracting with AUTHORIZATION I TOTAL FEE eT TOTAL 27 . 00
licensed contractors to construct the project (Section 7044, - 1 HAVE AT THIS DATE'A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO '' l
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CHECK 27.0(1
CONSTRUCTION LENDING AGENCY - CHANGE - ,p0
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 (Sac. 3097, Civ. C.). OWNERS AGENT (� ('1T'� r�
ADDRESS I+OOD-UW 1 1�?S/T r I
Lender's Name 2539 1 AM 8:13L
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 Plumbing and'Sewers,
and hereby authorize representatives of this County to enter
Upon the above-Me ned property for Ins action purposes. �7
Signature of Perm iltee Date SEE REVERSE FOR EXPLANATORY LANGUAGE