HomeMy Public PortalAbout5116 DOREEN AVE_Sewer__ WORKERS'COMPENSATION DECLARATION I
20 00516A642 DPW 6189 U
O h ,'el�y affirm that have a certificate of consent to self T6A6420
insure, or a certificate of Wor4er"s' Compensation Insurance, or
�o certified cropyhhereof (Sec. 3800, Lob C.) APPUCATION FOR PERARI4
Pa_Fcli N1.o. - 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.
Dole Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION DEPTH
COMPENSATION INSURANCE ADDRESS /�Q�� A�/ � a' O
ROM
(This section need not be completed d the work involved by the LOCALITY CROSS ST. C MANHOLE REFERENCE t0WEP
permit is for one hundred dollars ($100) or less.)
IF
I certify that in the performance of the work for which this
NEAREST r TYPE OF CONNECTION LEN THFr CURB PL ML iOPL
permit is issued, 1 shall not employ any person in any manner LEGAL PC NO
so as to become subject to the Workers Compensation Laws. DESCRIPTION LOT NO. CO IMP NO /OB NO
BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of ASSESSOR q.� O/] AFFIDAVIT WAIVER EASEMENT RECORD INSr4 NO DATE
MAPAPBOOK PAGE IZT/ PPRCEL (y'
Exemption, you should become subject to the Workers' p{ NO OF BLDGS.
Compensation provisions of the Labor code. you must forthwith SIZE OF LOT �X a Ear Now ON LOT HWY OR St WIDENING
comply with such provisions or this permit shall be deemed USE OF r
revoked. BUILDING ' z dGh V J(r 57ATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION PERMIT NO
�� kVC�
I hereby affirm that I am licensed under provisions of Chapter OWNER
9 (commencing with Section 7000) of Division 3 of the Bust- MAILADDRESB '/¢ 71C�.-e�.f �Q`
�J CHARGES
I and Professions Code, and my license is in full force and
effect, CITY (,j J/ TEL No I /7rJ V� 2 CONNECTION CHARGE FEE
License Number Lic.Class - REIMBURSEMENT FEE
-
CONTRACTOR 14 i III
DISTRICT NO GROUP MAP PROCESSED BY
Contractor Date
ADDRESS BIT PG
❑ 1 am exempt under Sec of the,L.A, Co. 1`, ��,L� r
CITY TEL.NO. !! .<` 4
O
Plumbing Code and/or Sec. of the STATE LIG FINALO
LICENSE NO. CLASS DATE �J �A'LIDRTION
B. 8 P, Code for the following reason N0. DESCRIPTION OF WORK FEE —/)L4_ J __(Ir LIQ T1�
HOUSE SEWER CONNECTING TOFINAL _ 1I
Date PUBLIC SEWER Br i T�rl, (J
SEPTIC TANK SEEPAGE PIT OR 1 ITEMS W
Pn5 AND OR MANN DO v a
Signature TOTAL 59 A. Jp
HOUSE SEWER CONNECTING 10
OWNER-BUILDER DECLARATION PRIVATE DisvosAl sysrfm
I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR GHEGK. 59—K!
Low for the following reason (Secton 7031.5, Buisness and Pro- WORK TO HOUSE SEWER
f ssi ns Code): OVERFLOW
E%TN CESSPOOL.DRTWELL SEEPAGE PIT DRAINFIELD CMANHOLE 'HHN6E .01)as 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 a, offered for sale (Section 7044, Business (�f1(I-(If1Q1 .:11619_;
and Professions Code). .�I,as owner of the property, am exclusively contracting with =•19 r' 1 {3M �.:.q
LI
OWNERS Permit
licensed contractors to construct the projeu (Section 7044,
tr $
Business and Professions Code). AUTHORIZATION TOTAL FEE
CONSTRUCTION LENDING AGENCY I HAVE AT TINS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO D
I hereby affirm that there is o 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
Lender's Name oWNEVS AGENT
ADDRESS
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-mentioned property for inspection purposes.
Signature of Perm ltlee Dote SEE REVERSE FOR EXPLANATORY LANGUAGE -