HomeMy Public PortalAbout5117 FARAGO AVE_Sewer__ WORKERS' COMPENSATION DECLARATION
< here6y' affirm that I have a certificate of consent to self 76A64t DPW 6/89
in1sure, or,o clertificate of Workers' Compe-psation Ins nce, or , y6ABa2D
a ce>YifNo c t Ccs (Sem n800, D .)"— �� APPLICATION FOR PERMIT
ElCertified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
Certified copy is filed with the county tion COUNTY OF LOS ANGELES BUILDING AND SAFETY
Dot�d a mens.
Applica FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING ATION DEPTH
COMPENSAT IO URANCE ADDRESS ��
(This section need not be comp if Involved by the MANHOLE REFERENCE UPPER
LOCALITY LOWER
permit is for one hundred dollars ($1 or less.)
NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. Y CURB P L ML TOP 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
BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
Date Applicant
NOTICE TO APPLICANT: If, after makingthis Certificate Of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
MAP BOOK 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
PERMIT NO
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter OWNER
9 (commencing with Section 7000) of Division 3 of the Busi- MAIL
ADDRESSI�/ /��� CHARGES
Hess and Professions Code, and my,license is in full force and
effect. �f`7/'/r/„_ CITY �. TEL.N / CONNECTION CHARGE FEE
License Number L�`' A Ic.Class C/-� REIMBURSEMENT FEE
/� /`.,'/ CONTRACTOR �'�'
COn1rOC10r J LII/)ZI,41 q e DISTRICT NO GROUP MAP PROCESSED BY
ADDRE 7 BK PG
❑ I am exempt under Sec. of the L.A.Co. f� � Jt'D 3 a.
CITY TEL.NO. d
Plumbing Code and/or Sec. of the srnTE v.. LIC. _ FINAL O
LICENSE NO. f � CLASS DATE VALIDATION
B. & P. Code for the followin ason NO. DESCRIPTION OF WORK FEE 6 Z
O
FINAL
HOUSE SEWER CONNECTING TO H
Date PUBLIC SEWER BY W
SEPTIC TANK SEEPAGE PIT OR d
Signatur PITS AND OR DRAINREID Tn
HOUSE SEWER CONNECTING TO ® Z
OWNER;�BUILDER ARATION PRIVATE DISPOSAL SYSTEM —
I hereby affirm that am e pt from the Contractor's License CONNECT ADDITIONAL BLDG OR
Law for the followi ason (Secton 7031.5, Buisness and Pro- WORK TO HOUSE SEWER t
INFIELD
fessionS Code): O TEN.CESS OOLGDRYWEE PIT DLRAMAN OLE - -
❑ I, as owner of the property, or my employees with wages as ALTER REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
their sole compensation, will do the work and the structure is not intended or offered for sole (Section 7044, Business _
and Professions Code). _
❑ 1, as owner of the property, am exclusively contracting with OWNERS Permit $
licensed contractors to construct the project (Section 7044,
Business and Professions Code). AUTHORIZATION TOTAL FEE
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO ..-. ,
I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER
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
+ ._.
1 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 outhori� r presents . of this County to enter
upon the above-men ' nperty or inspection purposes.
Signature of Permittee Date / SEE REVERSE FOR EXPLANATORY LANGUAGE