HomeMy Public PortalAbout8902 ELM AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self 1s
Snsure, or a certificate of'Workers'Compensation Insurance, or 76A642D J�
a Policy
o .ibQ �of am, 3800 . aD.C. +�„ PES 08(REV.8/81) . APPM �1AU�ON FOR ^ERMOU
Polic No (�/ am, an �f �Lpp1(V ppnII1I�VVI IIIY\!1 IIII111J 111011❑l�\v//I❑1
❑ Certified copy is hereby furnished. SEWER a SEWAGE DOSPOSG'L
XCertified copy is filed wit t c Unty buildin inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
' !!Date e Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXE TION'FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDRESSo STATION �j DEPTH
(This section need not be completed if the work involved by the LOCALITY MANHOLE REFERENCE / ^ d) OPP
WER
permit is for one hundred dollars ($100)or less.)
I certify that in the performance of the work for which this CROSSSST. TYPE OF CON N LENGTH FROM
Y. CURB P.L. M.L.TO P.L.
permit is issued, I shall not employ any person in any manner � x
so as to.become'subject to the Workers'Compensation Laws. P.C.NO.
OWNER fi CO.IMP.NO. JOB NO.
MAIL -701 LYS D"S
TRUNK PERMIT NO. ROAD PERMIT NO.
.Date Applicant ADDRESS A
NOTICE TO APPLICANT: If, after making this Certificate of CITY NO. /( AFFIDAVIT WAIVER EASEMENT RECORD.INSTR:NO. DATE
Exemption, you should become subject to the Workers' LEGAL /
Compensation provisions of the Labor code, you must forthwith DESCRIPTION. LOT NO.
comply with such provisions or this permit shall be deemed HWY.OR ST.WIDENING
revoked. BLOCK TRACT STATE ENCROACHMENT /
' LICENSED CONTRACTORS DECLARATION No.OF BLDGS. PERMIT NO.
SIZE of LOT Now ON Lor
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
y
�.
License Number Lic.Class ADDR REIMBURSEMENT FEE O
jI� l DISTRICT NO. • GROUP' MAP PRO SED BY U'
Contractor Date CITY / [ TEL.NO. 6' K. PG•, z
❑ 1 am exempt under Sec: of the L.A.Co. LICENSE NO. CLASS ®� ��� / 0
.,-
Plumbing Code and/or Sec. of the NODESCRIPTION OF WORK FEE FINAL � �
HOUSE SEWER CONNECTING TO ' DATE �/ VALIDA ON
PUBLIC SEWER �G
B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR FIN ;28311,7A'
PITS AND/OR DRAINFIELD _
Data HOUSE SEWER CONNECTING TO BY # 0 0 o O,1 .0
PRIVATE DISPOSAL SYSTEM -
Signature CONNECT ADDITIONAL BLDG.OR ail� C
WORK TO HOUSE SEWER D - - 21,5 O
OWNER-BUILDER DECLARATION 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 HOU O O - 21. .5,o U .
fessions Code): - SEWER OR DISPOSAL SYSTEM
❑ I,as owner of the property,or my employees with wages asv 1. 1 2' 8 7
their sole compensation,.will do the work and the structure Oft Oct&!Err2
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permit $
❑ 1,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
BUSIneSS and PfOfeSSlOnS Code). - CONNECT THE ABO E DESCRIBED EXISTING DWEL dG TO THE PUBLIC SEWER'
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency SIGNED THE
DAY 1
for the performance of the work for which this'permit is OWNER OR
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
ordin c and State laws regulating Plumbing and Sewers,
a ere y authorize representatives of this County to enter
up"the bov me I ned pr ty for ins tion purposes.
Ignatire of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE