HomeMy Public PortalAbout4931 ENCINITA AVE_Sewer__ WORKERS' COMPENSATION DECLARATION
I^hweby affirm that I have a certificate of consent to self 92 0002 DPW 3/87
Insure, or a certificate of-Workers'Compensation Insurance, or 08 D
CE 8
a certified copy theW-o((Sec 3800, Lab C > CE 808 APPLICATION FOR PERMIT
Policy No + Company Os
Certified copy is herebvv furnished SEWER - SEWAGE DISPOSAL
El
❑ Certifle J copy s f let!Vith the county buildingi pection CO TY OF LOS ANGELES BUILDING AND SAFETY
dep t ent
Date 90 plicant FOR APPLI ANT TO FILL IN CON ECTION DAT
C RTIFIC E OF EXEMPTION FROM WORKERS' 5ADDRESSA15M
MPENSATION INSURANCE ' o K1 ITA
N DEPTH(This sect) need not be completed if the work Involved by the cAnr MANHOLE REFERENCE 1.qIAaJ_ UPPER
permit Is for one hundred dollars ($100)or less ) / va TYPE OF CONNECTION LENGTH FROM
I certify that I the performance of the work for which this Y CURB P L MIL TOP L
permit I Issue I shall not employ any person In any manner
so as to beco subject to the Workers'Compensation Laws OWNER Co IMP NO JOB NO
j R J MAIL TRUNK PERMIT NO ROAD PERMIT NO
Dat C `Rppl scant L/� A ADDRESS
NOTICE O A LICANT If, after making this Cerlifi to of CITY TEL NO AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
Exempt) n, yo should become subject to the orkers' LEGAL
Compen ation 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 ENCROA ENT
LICENSED CONTRACTORS DECLARATION NO OF BLDGS PERMIT NO l
SIZE OF LOT NOW ON LOT a
I hereby affirm that I am licensed under provisions of Chapter USE OF C7
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES
ness and Professions Code4amy license is in full force and
CONNECTION CHARGE FEE
effect CONTRACTOR
Y �
License Numb LI Class ADDRESS REIMBURSEMENT FEE d
���� 'Q DISTRICT NO GROUP MAP P ESSED BY O U
Contractor 5-_ t CITY TEL NO
- STATE BK PG �
El am exempt under Sec of t e L CO LICENSE N CLASS '51 10
RJ-
NO DES IPTION OF W K FEE
Plumbing Code and/or Sec of the FINAL ` W
N
HOUSE SEWER CONNECTING TO DATE O VALIDAT
B & P Code for the following reason PUBLIC SEWER n.
SEPTIC TANK SEEPAGE PIT OR N
PITS AND/OR DRAINFIELD FINAL
Date HOUSE SEWER CONNECTING TO BY
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
Low for the following reason (Secton 7031 5, Buisness and Pro- ALTER REPAIR OR ABANDON HOUSE
fessions Code) SEWER OR DISPOSAL SYSTEM
❑ I,as owner of the property,or my employees with wages as
their sole compensation, will do the work and the structure 05 6.2 A
is not Intended or offered for sale (Section 7044, Business
and Professions Code) OWNER'S Permit $
AUTHORIZATION $$ ° o ° °,1 0
❑ I, as owner of the property, am exclusively contracting with TOTAL E
licensed contractors to Construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT W HE IN NAME CONTRACTOR TO • - 27.50
Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXI O C SEWER
CONSTRUCTION LENDING AGENCY 0 0 0 2 7.5 O v
j 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 3t1 8 8
P p OWNERS ENT
Issued (Sec 3097, Civ C )
ADDRES
i
Lender's Name
Lender's Address
I certify that I have read this application and state that the
above Infor tion is correct I agree to comply with all County
ordinance nd State laws ulatin Plumbin and Sewers,
and her authorizer res ativ of t aunty to enter
upon a ave-men oper fo pection purposes
Signature of Permittee Jilliate SEE REVERSE FOR EXPLANATORY LANGUAGE