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HomeMy Public PortalAbout5438 ENCINITA AVE_Sewer__ WORKERS' COMPENSATION DECLARATION �j I hereby affirm that I have a certificate of consent to self 20-DOST DPW 6189 Insure, or a aerhficate•of.$�Workers'Compensation Insurance, or 76A642D Lob C PolcyfNo. � Cor7p nB��Wu�E .c�, APPLICATION FOR PERMIT 1:1 Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. a Dote�(,y 1(��5.Applicant C:wr412," I� FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION DEPTH COMPENSATION INSURANCE ADDRESS (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 C� LOWER certifythat in the performance Of the work for Which this NEAREST TYPE OF CONNECTION LENGTH FROM p CROSS ST. C Y CURB P L M L TO P L permit is issued, 1 shall not employ any person in any manner LEGAL so as to become subject to the Workers' Compensation Laws. DESCRIPTION LOT NO. P C NO I P CO IMP NO JOB NO BLOCK TRACT \3 TRUNK PERMIT NO ROAD PERMIT NO Date Applicant . �y ASSESSOR l/71•� AFFIDAVIT I WAIVER EASEMENT RECORD INSTR NO DATE NOTICE TO APPLICANT: If, after making this Certificate of MAPBOOK PAGE PARCEL GCa Exemption, you should become subject to the Workers' No.OF BLDGS. Compensation provisions of the Labor code, you must forthwith SIZE OF LOT O NOW ON LOT HWV OR ST WIDENING comply with such provisions or this permit shall be deemed USE OF a ` revoked. BUILDINGS V ♦ �a- STATE ENCROACHMENT PERMIT NO LICENSED CONTRACTORS DECLARATION OWNERQFj G I hereby affirm that I am licensed under provisions of Chapter 1,,,� 9 (commencing with Section 7000) of Division 3 of the Busi- nooaEss ,� yvs� �L�'�` �`f�♦ CHARGES ness and Professions Code, and my license is in full force and �7 p f^1 effect. CITY 61 TEL.NO. g(p '��©�{�`� CONNECTION CHARGE FEE License Number �� �Lic. Class e�. REIMBURSEMENT FEE f�^ CONTRACTOR �Cy �, Contractor .4 hDate \y^� �M `( DISTRICT NO GROUP MAP PROCESSED BY ��r l�• �_ ADDRESS ��i� y�i�ll� �j �/ �'! .{ BK PG ❑ 1 am exempt under Sec. of the L.A.Co. CITY TEL.NO. g 3, — Zd �/' oV /E-3 G'" IL Plumbing Code and/or Sec. of the STATE LIC. FINAL V LICENSE NO. Q 3 CLASS DATE 7 VALIDATION Z B. & P. Code for the following reason NO. DESCRIPTION OF WORK FEE _Z O 1 HOUSE SEWER CONNECTING TO LL,/ L FINAL 1— Date ` PUBLIC SEWER '7� 7 BY SEPTIC TANK SEEPAGE PIT OR LULU Signature PITS AND OR DRAINFIELD 0. OWNER-BUILDER DECLARATION HOUSE SEWER PRIVATE DISPOSSALAL SYSTEM ro YS I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR Law for the following reason (Secton 7031.5, Buisness and Pro- WORK TO HOUSE SEWER feSSiOnS Code OVERFLOW SEEPAGE PIT DRAINFIELD -`- ExTN.CESSPOOL, DRYWELL.MANHOLE __ ❑ 1, as owner of theproperty, Or m em to employees with wages as ALTER.REPAIR OR ABANDON HOUSE AC.C-1 e Y P Y 9 SEWER OR DISPOSAL SYSTEM their sole compensation, will do the work and the structure 'y^- t^.•_ti(_I is not intended or offered for sale (Section 7044, Business j`•[_,� and Professions Code). ❑ I, as owner of the property, am exclusively contracting with /�/ —r —z licensed contractors to construct the project (Section 7044, OWNER'S Permit $ • "4 fj Mi,i; `y( — �;•___ Business and Professions Code). AUTHORIZATION TOTAL FEE '77 3 Q "HEC:I 72 3C j CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO Pilo. I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER „ for the performance of the work for which this permit Is issued (Sec. 3097, Civ. C.). SIGNED THIS DAY OF X19_ OWNER 9 Lender's Name OWNERSOAGENT `_:).100`1)f..0 4 5:'1 j,`�;.`T Lender's Address ADDRESS f r41 y _ AM J= 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 the above-mentioned property for inspection purposes. oture of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE