HomeMy Public PortalAbout5111 FARAGO AVE_Sewer__ ♦ WORKERS' COMPENSATION DECLARATION zo-oo5T DPW 6189
A 'rt 6y"cffirSn that I have a certificate of consent to self 70-0051
Insure, or a certificate of Workers' Compensation Insurance, or
a certified f Sec. 3800, L , APPLICATION FOR PERMIT
Policy N� ompany SEWER - SEWAGE DISPOSAL
❑ Certified copy is hereby furnished.
Certified copy is filed with the county u' spection COUNTY OF LOS ANGELES BUILDING AND SAFETY
d art e t.
Dat l r ppIican FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM R ATION DEPTH BUILDING
COMPENSATION INSURA ADDRESS /� ,
(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
I certify that in the performance of the work for which this NEAREST TYPE OF CONNECTON
LENGTH FROM
CROSS ST. Y CURB P L ML TOPI,
permit is issued, 1 shall not employ any person in any manner LEGAL
so as to become subject to the Workers' Compensation Laws. DESCRIPTION LOT NO. PC NO
CO IMP NO LOB NO
Date Applicant BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
NOTICE 70 APPLICANT: If, after makin this Certificate Of. ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
9 MAPBOOK PAGE PARCEL
Exemption, you should become subject to the Workers' No,OF BLDGS.
Compensation provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT HWY OR ST WIDENING
comply with such provisions or this permit shall be deemed USE of
revoked. BUILDINGS STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION 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
Hess and Professions Code, and my license is in full force and ADDRES / - CHARGES
effect. _ CITY [. TEL.N CONNECTION CHARGE FEE
License Number-y"I" /w Lic.Class
REIMBURSEMENT FEE
ContractorL '✓�i�.D�rfe ?�.�`1Cl CONTRACTOR
.� � DISTRICT NO GROUP MAP PROCESSED BY
I — I I ADDRESS
BK PG
❑ 1 am exempt under Sec. of the L.A.Co. �o CI, a
CITY I k— �
Plumbing Code and/or Sec. of the STATE �—�/// _/— CLASS — FINAL 0
LICENSE NO. �••�P�-� DATE Q,�r VALIDATION Z
B. 8 P. Code for the followin reason NO. DESCRIPTION OF WORK FEE O
HOUSE SEWER CONNECTING TO FINAL
ate PUBLIC SEWER By U
SEPTIC TANK SEEPAGE PIT OR W
SIgnaIur PITS AND OR DRAINFIELD d
OWNER-5AD HOUSE SEWER CONNECTING TO V)
ARATION PRIVATE DISPOSAL SYSTEM , z
I herebyaffirm that I a t from the Contractor's License CONNECT ADDITIONAL BLDG OR
Law for the following reason (Secton 7031.5, Buisness and Pro- WORK TO HOUSE SEWER
fessions Code): OVERFLOW SEEPAGE PIT, DRAINFIELD --
EXTN.CESSPOOL.DRYWELL.MANHOLE '
❑ I, as owner of the property, or my employees with wages as ALTER.REPAIR OR ABANDON HOUSE ;+Iw„ ;.•;
SEWER OR DISPOSAL SYSTEM
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business
and Professions Code). _
❑ I, as Owner of the property, am exclusively contracting with OWNERS Permit
licensed contractors to construct the project (Section 7044,
Business and Professions Code). AUTHORIZATION I TOTAL FEE
CONSTRUCTION LENDING AGENCY I HAVE AT THIS 'DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO -"
CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER
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 M •� µ
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers,
and hereby a thOrize rf,�eqtcttives of this County to enter
ab
upon the;b:; e ne o rty for inspection purposes.
gnature of Permitte Date SEE REVERSE FOR EXPLANATORY LANGUAGE