HomeMy Public PortalAbout5115 FARAGO AVE_Sewer__ WORKERS' COMPENSATION DECLARATION 20-oD5t DPW ele9 �t I
tierel�y affirm that I have a certificate of consent to self 70-0051 U
insure, or Wcetific ote f Workers' Compens tion Insurance, ora'cer'tifiedec. 3800 APPLICATION FOR PERMIT
Policy IN mpany
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
Certified copy is filed with the county bu n COUNTY OF LOS ANGELES BUILDING AND SAFETY
d artment. /
Dat n� A Iicont FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' 7BUILDIN � /�—
COMPENSATION INSURAN ADDRESS V �l STATION DEPTH
(This section need not be completed if the war involved by the MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100) or less.)
LOCALITY LOWER
I certify that in the performance of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROMcaoss ST. v CURB P L M L r0 P L
permit is issued, 1 shall not employ any person in any manner LEGAL PC No
so as to become subject to the Workers' Compensation Laws. DESCRIPTION LOT NO, CO IMP NO JOB NO
Date Applicant BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
NOTICE TO APPLICANT: If, after making this Certificate Of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
g MAPBOOK PAGE PARCEL
Exemption, you should become subject to the Workers'
NO.OF BLDGS.
Compensation provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT HWY OR ST WIDENING
comply with such provisions or this permit shall be deemed USE OF
revoked. BUILDINGS STATE ENCROACHMENT
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LICENSED CONTRACTORS DECLARATION PERMIT NO
I hereby affirm that I am licensed under provisions of Chapter OWNER
9 (commencing with Section 7000) of Division 3 of the Busi- MAIL
ness and Professions Code, and my license is in full force and ADDRES ( CHARGES
effect. CITY ( TEL. CONNECTION CHARGE FEE
/
License Number L Lic.Class REIMBURSEMENT FEE
CONTRACTOR
ContractorAllto �� L DISTRICT NO GROUP MAP PROCESSED BY
ADDRESS
BK PG
ElI am exempt under Sec. of the L.A.Co. >_
CITY TEL.NO. � �� -3 �L�,�t,( O
Plumbing Code and/or Sec. of rhe STATE LIC. FINAL U
LICENSE NO. 1 CLASS DATE VALIDATION
B. 8 P. Code for the followin reason NO. DESCRIPTION OF WORK FEE (tJ�( Z
HOUSE SEWER CONNECTING TO FINAL
Date PUBLIC SEWER By V
SEPTIC TANK SEEPAGE PIT OR W
Signatu PIT$AND OR DRAINFIELD N
O
ECLARATION HOUSE SEWER CONNECTING TO ® Z
PRIVATE DISPOSAL SYSTEM _
I hereby affirm th aWNE �BUILD
the Contractor's License CONNECT ADDITIONAL BLDG ORLaw for the fall Ing reon 7031.5, Buisness and Pro- WORK TO HOUSE SEWER i
fessions Code OVERFLOW SEEPAGE PIT. DRAINFIELD
EXTN,CESSPOOL, DRYWELL.MANHOLE •;'„l-i n
i
❑ I, as owner of the property, or my employees with Wages a5 ALTER.REPAIR OR ABANDON HOUSESEWER 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,'
❑ I, as owner of the property, am exclusively contracting with OWNERS Permit $ •'_` " :. ~A -r
licensed contractors to construct the project (Section 7044,
Business and Professions Code). AUTHORIZATION I TOTAL FEE i ` _:'•
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
I _
I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE Pu6uc SEWER - -• --for the performance of the work for which this permit is
issued (Sec. 3097, Civ. C.). SIGNED THIS DAY OF )9—
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 regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes.
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE