HomeMy Public PortalAbout8943-8951 EMPEROR AVE_Sewer__ WORKERS' COMPENSATION DECLARATION
r'eby"affirm 1that_ J.%ave a certificate of consent to self 76A642 DPW 3/87
in-sure, or a'ceriificate of Workers'Compensation Insurance, or CE 808 D
a certif4d-cd p�jthereof Sec. 3800, b C.) CE 808 APPLICATION FOR PERMIT
Policy NWJ-eQ [-3fD mpony , es
F-1Certifiedcopy is hereby furnished. SEWER - SEWAGE DISPOSAL
❑ Certified corps is filed withrtur�y b,�ing inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
Date ep�rt Applicant _9St� ' FNEARE
FOR APPLICANT TO FILL IN CONNECTION DATA
l CERTIFICATE OF EXEMPTION FROM WORKERS' �` STATION DEPTH
COMPENSATION INSURANCE YpY SJ L✓
(This section need not be completed if the work involved by the MANHOLE REFERENCE UPPER
LOWER
permit is for one hundred dollars ($100) or less.)
TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this Y. CURB P.L. M.L.TO P.L.
permit is issued, I shall not employ any person in any mannerr
P.C.NO.
so as to become subject to the Workers'Compensation Laws. OWNER A
EQ}J. �• CO.IMP.NO. JOB NO.
MAIL ' 1 V TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRES V
boa NOTICE TO APPLICANT: If, after making this Certificate Of CITY TEL.NO. AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
l5�c
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
6 -7
NO.OF BLDGS. PERMIT NO.
Q
LICENSED CONTRACTORS DECLARATION SIZE OF LOT NOW ON LOT �^
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 (rr
effect. r (,/ CONTRACTO —II�tC.' '�sS:•-a l9 CONNECTION CHARGE FEE
License Num er`�7 / LIC.Class Ws� ,11nn,,'' ,,, L REIMBURSEMENT FEE a
ADDRESS L OY � r, f
7, � G ^k q&2-_Z,/�d_ DISTRICT NO. GROUP MAP PROCESSED BY O
Contractor Date ! J / CITY K�, �/j�� •TEL.NO. ( "��G� �C // nU
STATE Q moi, LIC. �` 1 J BK PG O
❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. �G �/ CLASS (2-3 ie +�(ti
NO. DESCRIPTION OF WORK FEE U
Plumbingiq -71
Code and/or Sec. of the FINAL
HOUSE SEWER CONNECTING TOPUBLIC SEWER
DATE D c Y VALIDATI N CL
r; /
B. 8 P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR W
FINA
PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER L ��
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 (Sectors 7031.5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM g 0 0 nn
7,b
❑ I,as owner of the property,or my employees with wages as #'0',0 o m,1 0
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, BusinessPermit g 8 2 5 0
and Professions Code). OWNERS
❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE o ° o 8 2 5 0 5
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED RACTOR TOQ 8
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. O 7.0 8
CONSTRUCTION LENDING AGENCY ►
I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19OWNERR _
for the performance of the work for which this permit is OWNERS AGENT
issued (Sec. 3097, Civ. C.).
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
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upon t bove- ioned pro erty for inspection purposes.
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE