HomeMy Public PortalAbout5109 FARAGO AVE_Sewer__ WORKERS' COMPENSATION DECLARATION 20-oo5T DPW Bt89 �i I
T k,ereby otfilrm that I have a certificate of consent to self 70-0051 (�
Insure, or a certificate of Workers' Com e sari n I nnce, o P
o certified f om . 3800 a ) �++•_ APPLICATION FOR PERMIT
Policy No?
EJCertified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
Certified copy s filed with the county beildin lin n COUNTY OF LOS ANGELES BUILDING AND SAFETY
Date ucani FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTI N FROM WORKERS' BUILDING f
COMPENSATION INSURANCE ADDRESS / STATION DEPTH
(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 LOWER
NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. Y CURB P L M L TO P I
permit is issued, I shall not employ any person ny manner LEGAL PC NO
so as to become subject to the Workers' pensation Laws. DESCRIPTION LOT NO, CO IMP NO TOB NO
Date Appl ica BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
NOTICE TO APPLICA If, after making this Certificate Of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
g MAPBOOK PAGE PARCEL
Exemption, you ould become subject to the Workers' NO.OF BLDGS.
Compensotio rovisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT HWv OR ST WIDENING
comply such provisions or this permit shall be deemed USE OF
revo BUILDINGS STATE ENCROACHMENT
�_
LICENSED CONTRACTORS DECLARATION A�Q PERMIT NO
I hereby affirm that I am licensed under provisions of Chapter OWNER
9 (commencing with Section 7000) of Division 3 of the Busi- MAIL '�
ness and Professions Code, and my license is in full force and ADDREs l CHARGES
effect. 7 �ni/J CITY C TEL.NO. � r CONNECTION CHARGE FEE
License Number / L,c Class _'� v CONTRACTOR REIMBURSEMENT FEE
�I
Contractor to ,p-- DISTRICT NO GROUP MAP PROCESSED BY
ADDRESS v' BK PG
❑ 1 am exempt under Sec. of the L.A.Co. q� d
CITY TEL.NO. �(Jr� 0-
Plumbing Code and/or Sec. of rhe STATE LIc. HNAL U
LICENSE NO. ( CLASS DATE VALIDATION Z
B. & P. Code for the following reason NO. DESCRIPTION OF WORK FEE O
HOUSE SEWER CONNECTING TO FINAL
PUBLIC SEWER BY (�
SEPTIC TANK SEEPAGEPIT OR !�.- W
Signature
' PITS AND OR DRAINFIELD d
O R-BUILDER DECLA HOUSE SEWER CONNECTING TO Gf CD
ON PRIVATE DISPOSAL SYSTEM
I hereby affIT t I am exempt from the Co tractor's License CONNECT ADDITIONAL BLDG OR
Law for the following reason
(Sect
7031.5, uisness and Pro- WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT DRAINFIELD
feSSiOnS Code): EXTN,CESSPOOL.DRYWELL.MANHOLE
ALTER, REPAIR OR ABANDON HOUSE
❑ I, as owner of the properemployees with wages OS SEWER OR DISPOSAL SYSTEM
their sole compensation, work and the structure
is not intended or offered for sole (Section 7044, Business
and Professions Code). —
1 i_.•.
❑ I, as owner of the property, am exclusively contracting with Permit $
licensed contractors to construct the project (Section 7044, OWNER'S
Business and Professions Code). AUTHORIZATION FTOTAL FEE /"/,. /J
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO , ^.i i:;
CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER •'x '=:^
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued (Sec. 3097, Civ. C.). SIGNED THIS DAY OF 19_
OWNER OR
Lender's Name OWNERS AGENT
Lender's Address 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 r g Plumbing and Sewers,
and hereby authorizer ntativ s of this County to enter
upon the abov�ti ed prop for inspection purposes.
Sig u e of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE