HomeMy Public PortalAbout5472 ENCINITA AVE_Sewer__ j RKERS' COMPENSATION DECLARATION —�7 —
i r` ;firm that I have a certificate of consent to self II
-a o,-,-ificote cf Workers' Compensation Insurance, or 76A642D J�
j a certified copy thereof (Sec. 3800, Lab C. CE BDB(REV.B,B,, APPLICATION FOR PERMIT
Policy No. Company s
❑ rtified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
CCeertified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
departure t. I
Date S� Applicant ��4 71G FOR APPLICANT TO FILL IN CONNECTION DATA
CER IFICATE OF EXEMPTION FROM WORKERS' BUILDING i./ j rte¢ STATION /� DEPTH/
COMPENSATION INSURANCE ADDRESS U' // �CJ3;� }O
(This section need not be completed if the work involved by the ! MANHOLE REFERENCE S� /s S O L ER
LOCALITY L� ,
permit is for one hundred dollars ($100)or less.)
NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. /L ,- �iC� Y. � CURB P.L. M.L.TO P.L.
permit is issued, I shall not employ any person in any manner .-� ;
��, P. BNO.
50 a5 f0 become subject to the Workers' Compensation LOWS. OWNER /.�(/•��"'ZC/ ,.,r CO.IMP.NO. JOB NO.MAIL, I
ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant _
AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
NOTICE TO APPLICANT: If, after making this Certificate of CITY G TEL.No. �j�i�� '
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO.
comply with such provisions or this permit shall be deemed HWY.OR ST.WIDENING
revoked. BLOCK TRACT STATE ENCROAC MENT J
LICENSED CONTRACTORS DECLARATION 7
NO.OF BLDGS. PERMIT NO.
SIZE OF LOT Z � NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter,, USE OF
9 (commencing with Section 7000) of Division 3 of,the Busi- BUILDINGS _S �Lc
ness and Professions Code, and my license is in full force and
effect. L �s CONTRACTOR , ' �!.} CONNECTION CHARGE FEE
License Number Z��1 ��I Lic.Class -U /j 0 `
' ADDRESS /y// °C^ REIMBURSEMENT FEE 0 (
j
Contractor Date DISTRICT NO. GROUP MAP PROCESSED BY
CITY TEL.NO. /� BK P 0
❑ I am exempt under Sec. of the L.A. Co. uCENSE No. cLAss Cif Y'
NO. DESCRIPTION OF WORK FEE V.
j Plumbing Code and/or Sec. of the FINAL VALI TION
' HOUSE SEWER CONNECTING TO DATE
B. & P. Code for the following reason PUBLIC SEWER
�?
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD FIN m
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM Q Z
Signature CONNECT ADDITIONAL BLDG.OR �8 1 3.7 A
WORK TO HOUSE SEWER
OWNER-BUILDER DECLARATION R
OVERFLOW SEEPAGE PIT,DRAINFIELD # 0 0 0 0;11 0
I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE
Law for the following reason (Secton 7031.5, BUlsness'and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM -1 o 627.5 0
❑ I,as owner of the property, or my employees with wages as
their sole compensation, will do the work and the structure 0 0 - 275 Q't
is not intended Or offered for sale (Section 7044, Business Permit g
and Professions Code). OWNER'S 6-87
EJ 1,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE �'
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EYISTING DWELLING TO THE PUBLIC SEWER.
I
CONSTRUCTION LENDING AGENCY
,
I hereby affirm that there is a construction lending agency SIGNED THISDAY OF 199 � I
for the performance of the work for which this permit is OWNER OWNERSOAGENT ` ` I
sued (Sec. 3097, Civ. C.). A y
ADDRESS j
Lender's Name
I
Lender's Address
1 certify that I have read this application and state thatthe
above information is-correct. I agree to comply with all County
i ordinances and State laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upon the above-mentioned prop(arty for i s (action purposes.
l Signatu of Pe tte Date SEE REVERSE FOR EXPLANATORY LANGUAGE