HomeMy Public PortalAbout6008 ENCINITA AVE_Sewer__ WORKERS'COMPENSATION DECLARATION _ o,
I hereby affirm that I have a certificate of consent to self /�'
insure, or a cepf±icow&Wttkers'Compensation Insurance, or 79AW113 �n pp
o certified copy thereof (Sac. 3800, Lob C.) az-aaaz DPW eras ap
Policy Na. ompany JYp APPU T %O#N �p FOR PERMIT
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Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL•t '1
Certified copy is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
depar mens. ,
Dole Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CER FIC TE OF EXEMPTI FRO ORKERS' BUILDING
COMPENSATION INSURANCE ADDRESS QOQ STATION DEPTH
(This section need not be completed if the work Involved by the MANHOLE REFERENCE` Oma
"permit is for one hundred dollars ($100)or less.) tacnury _
I certify that in the performance of the work for which this NEAARESTT. TYPE OF CONNECTION �� LENGTH FROM
Y. t CURB ;P.L'. M.L.TO P.L.
permit is issued, Iaholl not employ any person in any manner CROSS �)�,�
so as to become subject to the Workers'Compensation Lows. OWNER //7 CO.IMP.-NO.}•�\' ',- + toB rNio.
'NAIL TRUNK PERMIT NO. ROAD PERMIT NO. 5 1
Date Applicont ADDRESS AFFIDAVIT I WAIVER EASEMENT RECORD.INSiR.NO.q /� e.12-
/
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL.NO. AI! 7 E%� DATE
Exemption, you should become subject to the Workers LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR 57.WIDENING j •''
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT SLATE ENCROACHMENT
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LICENSED NO.OF ELMS. PERMIT N0,
CONTRACTORS DECLARATION SIZE OF LOT 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 . CHARGES
ness and Professions Code, and my license is in full force and
effect. 'E/ ^ CONTRACTOR
CONNECTION CHARGE FEE
License Numbee��Gr(�L/��y��A/��J(�,,,,'y/yyp¢¢¢�3��.�6..�7��/�4 Lit.Clan c 2� �C 3�/+��1� �RE� .� (+ p REIMBURSEMENT FEE .1 ' CYJ
Contractor� ()are�/� 90 CITY `I TEL.NO. i-0-2 ILO
DISTRICT NO. GROUP /BK MAP /� ROCES BY IO.
❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. Z S 3 7G CLA55�'L — 50 3 L / kQ
Plumbing Code and/or Sec. oflhe NO, DESCRIPTION OF WORK RE FINAL ' LU
HOUSE SEWER CONNECTING TO DATE VALIDAT IN fn
B. 8 P. Code for the following reason PUBLIC SEWER Z
SEPTIC TANK,SEEPAGE PIT OR FINAL
PITS AND/OR DRAINFIELD - •'
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR D
' OWNER-BUILDER DECLARATION WORN TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD
I hereby affirm That 1 am exempt from the Contractor's License "" CESSPOOL,DRYWEII,MANHOLE C^ 11
Law for the following reason (Secton 7031.5, Buisners and Pro- ALTER,REPAIR OR NDON HOUSE .,377
fessions Code): SEwER OR DISPOSAL SYSTEM
❑ I,as owner of the property,or my employees with wages as VO D
their sole compensation, will do the work and the structure �^.,) - .j!f
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permit E .10
. ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE 4 9
licensed contractors to construct the project Section 7044, CONTRACTOR . . Al'!.'T•
P I ( HAVE AL THIS DALE A CONTRACT WITH THE HEREIN NAMED TO •t Cr
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC YWER. 3 JlZ 34.5D
4• _)
CONSTRUCTION LENDING AGENCY 1 IT
I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_
OWNER OR r
for the performance of the work for which this permit is OWNERS AGENT O r'+ !"• -'H C•J q r+
issued (Sec. 3097, Civ. C.). 1` 2 C• E.1 �_? O TOTAL
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Lender's Name AooREss p•. C * .
a� IF
Lender's Address C1 fn P-i yM
L u � � CHANGE •�4
I certify that I have read is application and state that the �.. rFT
above information is c r . I.agree to comply with all County r�1 r�
ordinances and Slot s regulating Plumbing and'Sewers, VJ 3 1,)QQI I)1D1 .`.1�?� ''�U
and hereby thor' presentative, of Ihis County to enter , ..
09 1
Upon the ab v - ned pro r Inzpa tion purposes. �' 7 -
$ignatur tree ate SEE REVERSE FOR EXPLANATORY LANGUAGE -�+.� � n -a.
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