HomeMy Public PortalAbout5436 ENCINITA AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby oRirm shot I have a certificate of consent to self
insure,'or d.certificate of Workers'Compensation Insurance, or 76A"20
d certified copy thereof (Sec. 3800, Lab C.) 92-6602 DPW 6188 APPLICATION
Iia ,p TION FOR PERMIT
Policy No. Company. �'Ulr ��lLpp��'bi�L .�L'II�I pIIHY Y
Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL /I
Certified copy is filed with the county building in coon COUNTY OF LOS ANGELES BUILDING AND SAFETY III JI'
deport m nt.
Date x Applicant / FOR APPLICANT TO FILL IN CONNECTION DATA
RTIFIC TE OF EXEMPTI FROM WORKERS' BUILDING /
COMPENSATION INSURANCE ADDRESS STATION DEPTH
(This section need not be completed if the work involved by the MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY - ( _ .LOWER
NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. Y. cults PL. M .TO PA,
permit is issued, I shall not employ any, person in any manner ",F P.C.NO"
so as to become subject to the Workers' Compensati Laws. OWNER /• V� - CO.IMP.NO. JOB NO.
NAIL TRUNK PERMIT NO, ROAD PERMIT NO.
Date /Z pplicantADORE55 [� /� i-F
NOTICE TO A I ANT: I_f, after making this Certificate of CITY O AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.N0. DATE
Exemption, you •should become subject to the Workers' LEGAL 7�CS
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 Q
revoked. BLOCK TRACT & STATE ENCROACHMENT
- NO.of BLOT, PERMIT No
LICENSED CONTRACTORS DECLARATION .
SIZE OF LOT NOW ON LOT
i
I hereby affirm that I am licensed under provisions of Chapter USE of
9 (commencing with Section 7000) of Division 3 of the Busi- BUnDIrvGS CHARGES
ness and Professions Code, and my license is in full force and
effect. CONTRACTOR CONNECTION CHARGE FEE
License Number Lic.Class ADDRESS %/ / a REIMBURSEMENT FEE
Contra CtO ate DISTRICT NO. GROUP MAP PROCESSED BY
CITY TEL NO. /� rrrlll
STATE Z CLnSS OK // 0K PG �. /� }
❑ I am exempt under Sec. of the L.A.Co. LICENSE No. K N{L/`�- a
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WOR FEE
FINAL
/� I O
HOUSE SEWER CONNECTING TO !l DATE / / VALIDATION Ir
B. 8 P. Code for the following reason PUBLIC SEWER 0
SEPTIC TANK,SEEPAGE PIT OR FINAL 0
Dote PITS AND/OR DRAINFIELD
HOUSE SEWER CONNECTING TO BY ()
PRIVATE DISPOSAL SYSTEM W
Signature ` CONNECT ADDITIONAL BLDG.OR
_
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWEROVERFLOW SEEPAGE PIT,DRAINNELD Z
I hereby affirm that I am exempt from the Contractor's License ExTN.,CESSPOOL.DRYWELL,MANHOLE 10
Law for the following reason (Secton 7031.5, BUisness and Pro- ALTER,REPAIR OR ABANDON HOUSE q
fession5 Cade): SEWER OR DISPOSAL SYSTEM ... ACCT.
❑ I,as owner of the property,or my employees with wages as - - - --- -"
their sole compensation, will do the work and the structure 3307 27.50
is not intended or Offered for sale (Section 7044, Business - -'-""'
and Professions Code). OWNER'S P0ermit a .— 1 ITEMS
e��
r
El 1,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE TOTALTOTAL5O
licensed Contractors to construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO - — CHECK 27.50
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. F�LGGIA� C( Jl
CONSTRUCTION LENDING AGENCY CHAN& - .00
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
P P OWNERS AGENT
issued (Sec. 3097, Civ. C.).
Lender's Name ADDRESS u _ LIt,LULJ—EyJyi 12/13/89
Lender's Address 7501 1 AM11:32
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 cle laws regulatif ng Plumbing and Sewers,
and hereb t rize represen this County to enter
upo v nti y r inspection purposes.
Z /
ature of P Date SEE REVERSE FOR EXPLANATORY LANGUAGE