HomeMy Public PortalAbout5101 - 5107 FARAGO AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a cerfifica a of consent to self
insure, or a certificate of Workers'Co p nsation Insurance, or 76A642D CO
a certifie (Sec. 3800 C.) CE 808(REV. APPLICATION FOR PERMIT
Policy NCompany Os
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
1)5�Certified copy is filed with county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
de m t.
Dot��Applican PADDRESJ2?!eZ
nal FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' STATION DEPTH
COMPENSATION INSURANCE
(This section need not be completed if the work involved by the MANHOLE REFERENCE '--61 , PP
permit is for one hundred dollars ($100)or less.) L ER
I certify That in the performance Of the work for which this NEARETYPE OF CONNECTION LENGTH FROM
permit is issued, I shall not employ any person in any manner Y. CURB P,L. M.L.TO P.L.
P.C. NO.
50 OS f0 become subject to the Workers' Compensation Laws. 1� CO.IMP.NO. JOB NO.
TRUNK PERMIT NO. ROAD PERMIT NO.
DateApplicant O� AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
NOTICE TO APPLICANT: If, after making this Certificate of TEL.
Exemption, you should become subject to the Workers' 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
LICENSED CONTRACTORS DECLARATION No.OF BLDGS. PERMIT NO.
SIZE OF LOT Now ON LOT
I hereby affirm that I am licensed under provisions of Chapter USE OF o(d
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. ����� CONTRACTOR T9 CONNECTION CHARGE FEE y
License Nu _Lic.Class ADDRESS REIMBURSEMENT FEE
ContraC Date CITY TEL.NO. �UO DISTRICT NO. GROUP MAP PROCESSED BY 2E
STATE C=3—? LIC. PG 0
❑ I am exempt under Sec. of the L.A.Co. LICENSE No. � O(%a� CLASS
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL I U
HOUSE SEWER CONNECTING TO Q() DATE VALID ION
B. 8 P. Code for the following reason PUBLIC SEWERSEPTIC TANK,SEEPAGE PIT OR FI g
PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD
I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE V,(, n n
ff
fessions Code): SEWER OR DISPOSAL SYSTEM Z 7 [� 0
❑ I,as owner of the property,or my employees with wages as #.0 0t0 0'1 0
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business r.J to'62 7.50
and Professions Code), OWNERS Permit $
❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE 1.27. rD ° ° o27.50'0
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO '' q
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. O//µll 5 -88
CONSTRUCTION LENDING AGENCY ,
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
issued (Sec. 3097, Civ.-C.). OWNERS AGENT
ADDRESS
Lender's Name
Lender's Address
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 author' representatives of this County to enter
bove- boned property for inspection purposes.
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE