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HomeMy Public PortalAbout5326 EL MONTE AVE_Sewer__ :. WORKERS'COMPENSATION DECLARATION 76A642 DPW 3/87 I,hereby. a�ffrm .that I have a certificate of consent to self 76A642D insuC'e, or`a certificate of'Workers'Compensation Insurance, or CE BOB a cgrt' ied co ` thereof Sec. 3800, Lab C. 0 0 0 0 0 py ( ) appdO�Q��O1 FOR pCG3Gv��� Policy No. Company ©: - r� p El Certified copy is hereby furnished: SLOWER � SEWAGE DOSPOSAIs ❑ Certified copy is filed with th'e.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' BUILDING ^7/ / /Af / �/ , sTArION -*I— �, / DEPTH COMPENSATION INSURANCE ADDRESS L/10 •GL 0"/(J/V �(/V (This section need not be completed if the work Involved,by The MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less:) Locnury C 7 '� ��. 4Zt LOWER FROM I certifythat In the performance of theworkfor which this NEAREST `// - TYPE OF CON TION M.ILENG. P.I. P. CROSS ST. ® V G Y. C 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. 7' &7 +/ /JAL P.C. NO. . 'OWNER [.(. VVv 'J"(r cam. f-- �� COv IMP.NO. - !OB NO. MAIL �_. r�'/" / TRUNK PERMIT NO. ROAD PERMIT NO.- Date Applicant ADDRESS W9 V APPLICANT: If, after making this Certificate Of / AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTICE TO g. CITY��`T/V �C� 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 revoked. - BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS SIZE OF LOT DECLARATION NO.OF BLDGS: - PERMIT No. I hereby affirm that I am licensed under provisions of Chapter USE OF NOW ON LOT 9 (commencing with Section 7000,) of Division 3 of the Busi- BUILDINGS 1p CHARGES 1 ness and Professions Code, and my license is in full force and effect. CONTRACTOR I3 ae+(J CONNECTION CHARGE FEE License Number LIC.Class _ • - REIMBURSEMENT.FEE ADDRESS v d DISTRICT NO. GROUP MAP OCESSED BY Contractor Date O - CITY TEL.NO. P BK PG V EJI am exempt under Sec. oftL.A.Co. STATE LIC. S,Q� !�`3 0 LICENSE NO. CLASS Plumbing Code and/or Sec. of The 'NO. DESCRIPTION OF WORK FEE FINAL / HOUSE SEWER CONNECTING TO DATE ?' .VALIDATION lL PUBLIC,B. & P. Code for the following reason SEPTIC TANK, Z�1 C0 SEPTIC TANK,SEEPAGE PIT OR " FINAL z PITS AND/OR DRAINFIELD Date HOUSE.SEWER CONNECTING TO BY PRIVATE DISPOSAL'SYSTEM Signature CONNECT ADDITIONAL BLDG.OR ,may OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER t/� D (J/ 19P OVERFLOW SEEPAGE PIT,DRAINFIELD / 1•'� I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWEIL,MANHOLE »r.r. Law for the following reason (SectOn 7031.55, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM ❑ I,as owner of the property,or my employees with wages as the' sole compensation, will do the work and the structure ;':�; of intended or offered for sale (Section 7044, Business nd Professions Code). OWNERS Permit $ I, as owner of the property, am exclusively contracting with AUTHORIZATION r TOTAL FEE Ey 1 1,40 licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE.HEREIN NAMED.CONTRACTOR TO • Business and Professions Code), CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. IJ CONSTRUCTION LENDING AGENCY ; I hereby affirm that there is a construction lending-agency SIGNED THIS DAY OF 19_ D for the performance of the work for which this permit is OWNER OR j1 OWNERS AGEN_T - - - :r..R issued Sec. 3097, Civ. C. . y - ADDRESS Lender's Namer, I AN 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 tows regulating Plumbing and Sewers, and hereby authorize representatives of this County to enter Upon t above-mentioned prop y for inspection purposes. ` 2 -tet S ature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE