HomeMy Public PortalAbout9021 & 9027 EMPEROR AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
I• hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or 76A642D
a certified copy thereof (Sec. 3800, La , L CE8081REV.1/83) APPLICATION FOR PERMIT LI
Policy N&_Company
❑ Certified copy is hereby furnish d. SEWER - SEWAGE DISPOSAL
❑ Certified copy is filed with the county building inspection �Qa/ "7 COUNTY OF LOS ANGELES BUILDING AND SAFETY
department. /
Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING s STATION DEPTH 7
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work involved by the MANHOLE REFERENCE fS� �`®
permit is for one hundred dollars ($100)or less.) LOCALITY LOWER
NEAREST TYPE OF CONNEE CTIONLENGTH FROM
I certify that in the performance of the work for which this cRoss sr. Y. CURB P.L. M.L.TO P.L.
permit is issued, I shall not employ any person in any manner
P.C.No.
so as to become subject to the Workers'Compensation Laws. OWNER
CO.IMP.NO. JOB NO,
MAIL A TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS V
NOTICE TO APPLICANT: If, after making this Certificate of //•• / AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
g CITY � C.`D uJ TEL.NO. ���'p � /
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 DECLARATION NO.OF BLDGS. PERMITSIZE 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 ✓0-C pO �&1 iVef��. CHARGES
ness and Professions Code, and my license is in full force and
effect. ryo CONTRACTOR 64r.. , L....1 CONNECTION CHARGE FEE
License Number Lic.Class C� ADDRESS96
�',T}'-��\� ! nwl REIMBURSEMENT FEE 96
COniraCfOM `-'�� �- y 0
Date `�" '" CITY r 'TEL.NO. DISTRICT NO. GROUP /MAP. PR SSED B
STATE • LIC. h A j� a w/ 9 BK �
❑ 1 am exempt under Sec. of the L.A.Co. LICENSE NO. CLASS 3 �. a �V / 0
Plumbing Code and/Or Sec. of the NO. DESCRIP I W RK FEE
FINAL �'�^
HOUSE SEWER CONNECTING TO DATE 7 VALIDATION
B. & P. Code for the following reason r' PUBLIC SEWER
SEPTIC TANK,SEEPAGE PIT OR FINAL
/• PITS AND/OR DRAINFIELD BY �
• Date L- -r•�YSf HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR ,
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
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- SEWER RE DR OR
RABSYSTEM DON HOUSE z 2 33,6 A
fessions Code): # o o'o o 1 0
❑ I,as owner of the property,or my employees with wages as
their sole compensation, will do the work and the structure .1 o o 38.50
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permit $ p YO 0 to 0 38.5 00'
❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE 9 t
licensed contractors to construct the project'(Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO O if7 r2 8—8'4
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY �� A� ►
I hereby affirm that there is a construction lending agency OWNEROR
SIGNED THIS DAY OF E� 1
for the performance of the work for which this permit is OWNERS AGENT
issued (Sec. 3097, Civ. C.). `7
'
Lender's Name 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 a ove-m ned property for inspection purposes.
%i oture of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE