HomeMy Public PortalAbout4930 ENCINITA AVE_Sewer__ WORKERS' COMPENSATION DECLARATION
4 hereby offffm 'that I have a certificate of consent to self
'Jnsvrkof-a certificate of Workers'Compensation Insurance, Or 76A642D
.`Ic€rtified copy thereof (Sec. 3800, Lab C. CE 808(REV.8/811 APPLICATION FOR PERMIT
Policy No. Company es
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❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
~L] Certified copy is filed with the 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' fDSLING
COMPENSATION INSURANCE RES STATION DEPTH(This section need not be completed if the work involved by the �� MANHOLE REFERENCEfod / riPPE
permit is for one hundred dollars ($100)or less.) ALITY J NEARELOWER
I certify that in the performance Of the work for which this SSSST. t' TYPE OF CONNECTION LENGTH FROM
Y P.L. M.L.TO P.L.
permit is issued, I shall not employ any person in any manner cuRe
so as to become ubject to th orkers' Com nsatio Laws. OWNER ' CO.IMP.NO. JOB NO.
� � MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
Dated �/ p � ADDRESS
NOTICE TO APPLICANT: Ift akin this Certificate O{ AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
f, a
raking CifCITYrf
TEL.NO.
Exemption, you should bec 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. PERMIT O.
SIZE OF LOT NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter USE OF /
qm
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
License Number LIG.Class 1 REIMBURSEMENT FEE
ADDRESS 0
.Contractor Date DISTRICT NO. GROUP MAP PROCESSED BY U
CITY TEL.NO.
BK PG
❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. Ci SS (�Y ��� � S
NO. DESCRIPTION OF WORK FEE U
Plumbing Code and/or Sec. of the FINAL VALIDATION u"
HOUSE SEWER CONNECTING TO DATE
B. & P. Code for the following reason PUBLIC SEWER L7 OdSEPTIC TANK,SEEPAGE PIT OR g
PITS AND/OR DRAINFIELD 11N,11
Date HOUSE SEWER CONNECTING TO BY 1 e
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- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM 9 5 2 5 8 A
❑ I,as owner of the property,or my employees with wages as # 0 0 0 0 1 0
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business 11 o o27.50
�(and Professions Code). OWNER'S Permit $ o
til I,as owner of the property, am exclusively contracting with AUTHORIZATION I TOTAL FEE 570 o p0 o 2'�,5 0 5
Q
ee licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO 0 1 5-. 86
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY ,
I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_
for the performance of the work for which this permit is OWNER OR
issued (Sec. 3097, Civ. C.). // OWNERS AGENT
Lender's Name /J
�ir,/,�jL/n�� ADDRESS
Y7 CL`..GG,u/�'�
Lender's Address 7L' 404 -
I certify that I have read this app4W.tion and state that the
above information is correct. I agree to comply with all County
ordinances and State lows regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
u the above-mentioned p operty for inspection urposes.
n Ture of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE