HomeMy Public PortalAbout5825 ENCINITA AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have o certificate bf consent to self
insure, c,8 certificate of Workers'Compensation Insurance, or 76A642D
a certified copy thereof (Sec. 3800, Lab C.) BR-Boaz DPW Brea APPLICATION
PPn Itp. p!�I®gip 2®R PERMIT O
Policy No. Company !�U IL ` A Y N F IS 0 ,
certified copy is hereby furnished. SEWER SEWAGE DISPOSAL
❑ Certified copy is filed with the county building inspection
COUNTY OF LOS ANGELES BUILDING AND SAFETY o
departm nt, sq -
Date�� APPlicont FOR APPLICANT TO FILL IN CONNECTION DATA
ER FICATE OF EXEM I FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDRESS .J JrT I y-R STATION DEPTH
�i e
(This section need not be completed if the work involved by the �C �7 MANHOLE REFERENCE LOWER
permit is for one hundred dollars ($100)or less.) LOCALITY
NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. Y. CLraa P.L. M.L.TO P.L.
permit is issued, I shall not employ any person in a manner P. NO,
so as to b come subject to the Workers'Com sat o Laws. OWNER '^, CO.IMP,NO: J69 No.
wit TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS O0 OTR'G '�
NOTICE T PPLICANT: If, after Ing this Certificate of CITY ' � ( '� AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
[./t[yryCI.iEL.N0. D 3
Exemption, you should become subject to the Workeri 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 p
LICENSED CONTRACTORS DECLARATIONnq.OF BLDGS. PERMIT NO,
SIZE OF LOT NOW ON LOT IF 0
I hereby affirm that lam licensed under provisions of Chapter USE OF
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 �j �+
effect. CONTRACTOR 'TA,�,�j, CONNECTION CHARGE FEE
License Number2Lic.Pass. ADDRESS C/ '76
p REIMBURSEMENT FEE a
Contractor 67 /6 i DISTRICT NO. GROUP MAP ROCESSED BY
CITY /L TEL NO. ///��T
STATE LIC ' O "/ BK PG /E /7 }
❑ I am exempt u der Sec. of the L.A.Co. LICENSE NO. .� `.Z CLASS //' p/�(_/� a
Plumbing Code and/or Sec. of the. NO. DE CRIPTION O WORK FEE FINAL O
HOUSE SEWER CONNECTING TO AA 0 11 DATE / p VALIDATION o
B. & P. Code for the following reason PUBLIC SEWER 0 -
SEPTIC TANK,SEEPAGE PIT OR NAL PITS AND/OR AND/OR DRAINFIELD FINAL
/ U
HOUSE SEWER CONNECTING i0 !
PRIVATE DISPOSAL SYSTE .. .. ......_. ....._....-...... _ d
Signotur CONNECT ADDITIONAL BLDG:ORN
O NER-BUILDER D LARATION WORK TO HOUSE SEWER 7PZ
OVERFLOW SEEPAGE PIT, O
I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL.EIL MANHOLE 10
Law for the following reason (Section 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): , SEWER OR DISPOSAL SYSTEM ACC 1.i
❑ I,as owner of the property,or my employees with wages as - - - 3501 - 27.50
their sole compensation, will do the work and the structure - "---- ----
- -'- ' ' '
is not intended or offered for sale (Section 7044, Business permit _$ .�" 1 ITEMS
and Professions Code). OWNER'S _ ,
❑ I,OS Owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE ,`Z . ..-.- _ . . TOTAL 27 . 50 ,
licensed contractors to construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO E� n c _
Business and PrOfeSSiOnS Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER, CHECK 27.50
CONSTRUCTION LENDING AGENCY CHARGE ��)
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.). =AGENT 00W-0001
—0001 12/13/p
9
Lender's Name
Lender's Address 7498 1 AM11:32
I certify that 1 have read this opplicotI and state that the
above information is correct. I agr mply with all County - -
ordinances and State laws r lumbing and Sewers,
and hereby ep en Is of this County to enter
upon the t' MY for inspection ur ses.
Ignature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE