HomeMy Public PortalAbout9075 EMPEROR AVE_Sewer__ WORKERS'COMPENSATION DECLARATION CE8A6082(2 80) APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN CONNECTION DATA
BUILDING �JSTATION �� .� /�' / DEPTH
❑ Certified copy is filed with the county building inspection ADDRESS /G , ///
department. LOCALITY /�/'/ MANHOLE REFERENCE -2, LOWER
Date Applicant NEAREST / TYPE OF CONNECTIO LENGTH FROM
CERTIFICATE OF EXEMPTION FROM WORKERS' cRoss sT. j (� �!I Y. CU RB P.L M.L. TO P.L.
COMPENSATION INSURANCE �� P.C. NO.
OWNER .v CO. IMP. NO. JOB NO.
(This section need not be completed if the work Involved ADDRESS p�3 `/ /¢ �S / TRUNK PERMIT NO. ROAD PERMIT NO. d
by the permit is for one hundred dollars ($100) or less.) UO
`\ �] TEL. NJ S-` AFFIDAVIT WAIVER EASEMENT RECORD. INSTR. NO. DATE
CITY /+DI/' O. �7
I certify that in the performance of the work for wh'q this LEGAL W
permit is issued, I shall not employ any erson i an neer DESCRIPTION LOT NO.
HWY, OR Sl'. WIDENING
so as to become subject to rker Comp sat' La U
X
(� BLOCK TRACT STATE ENCROACHMENT UJ
�X a Date Applicant No. of BLDGS. PERMIT NO.
NOTICE TO APPLICANT: after making this NFtificate o SIZE: of LOT NOW ON LOT
Exemption, you should 43ecome subject to the Workers' USE OF
Compensation provisions of the Labor Code, you must forth-
BUILDINGS CHARGES
with comply with such '` / CONNECTION CHARGE FEE
p y provisions or this permit shall be CONTRACTOR `J /�
deemed revoked. REIMBURSEMENT FEE
LICENSED CONTRACTORS DECLARATION ADDRESS �() /� �5��' �Zf
I hereby affirm that I am licensed under provisions of Chapter DISTRICT NO. GROUP AlMPRo EsseD BY
CITY C,4i TEL. NO. i ,�S� L BK PG
9 (commencing with Section 7000) of Division 3 of the Busi- ,1 p�3 A
STAT� LIC.
A
ness and Professions Code, and my license is in full force and L CENSE NO. CLASS 6 v A" J
effect. NO. DESCRIPTION OF WORK FEE
/ HOUSE SEWER CONNECTING TO p FINALVALIDATIONy VALIDATION
/ License Number Lie.Class PUBLIC SEWER / DATE s 7 �j
II+' SEPTIC TANK,SEEPAGE PIT OR CJ C
r PITS AND/OR DRAINFIELD
Contractor Date FINAL
HOUSE SEWER CONNECTING TO BY
❑ PRIVATE DISPOSAL SYSTEM
I am exempt from the licensing requirements as I am a
CONNECT ADDITIONAL BLDG,OR
licensed architect or a registered professional engineer WORK TO HOUSE SEWER
acting In my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT,DRAINFIELD
iness and Professions Code). EXTN.,CESSPOOL,DRYWELL, MANHOLE
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
Lie.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION
X51, 01 A
1 hereby affirm that I am exempt from the Contractor's NEPermit f # o 0 0 0 1 Q
License Law for the following reason (Section 7031.5, Busi- FAUTOI0WR'S
RIZATION TOTAL FEE 2.0 -'l
ness and Professions Code):
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAM EO CON-
❑ TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING 1 Q 0 O
I, as owner of the property, will do the work and the TO THE PUBLIC SEWS 0.0 ° CJ 0
structure is not intended or offered for sale (Section SIGNED THIS DAY OF jln,4 19L
7044, Business and Professions Code). OWNER OR 0 -5 0 5—8 1
OWNERS AGENT
CONSTRUCTION LENDING AGENCY IWAV
ADDRESS
I hereby affirm that there is a construction lending agency 11
for the performance of the work for which this permit is
issued (Sec. 3097,Civ.C.).
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 Statelaws reg ing Plumbing and Sewers,
and hereby authorize represe a ves f this County to enter
u above- entio pr p rty inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig ture 0
f Permittee Da e