HomeMy Public PortalAbout5119 FARAGO AVE_Sewer__ WORKERS' COMPENSATION DECLARATION pO-DOST DPW 6189
I ber.ebo,dffirm that I have a certificate of consent to self L�
,insure, or a certificate of Workers' Compensation Insurance, or + 76A6a2D
a certified r ec. 3800, 1a c- APPLICATION FOR PERMITPolicy N� mpany ��
El Certified copy is her furnished. SEWER - SEWAGE DISPOSAL
Certified copy is filed with the county g in ection COUNTY OF LOS ANGELES BUILDING AND SAFETY
Date ` i pplicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXE ION FROM WOR BUILDIN !�
COMPENSATION INSURANCE ADDRES G STATION DEPTH
(This section need not be completed if the work inv d by the ,MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($1 � or
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 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 Lows. DESCRIPTION LOT NO, CO IMP NO JOB NO
Date Applicant BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
NOTICE TO APPLICANT: If, offer making this Certificate Of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
9 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
`...
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
ADDRESS CHARGES
ness and Professions Code, and my license is in full force and
effect. ! //�//'/� (/�/�1 CITY r TEL.N / .� .6 ONNECTION CHARGE FEE
License Number ( Lic. Class � � REIMBURSEMENT FEE
CONTRACTOR
Contractor t DISTRICT NO GROUP MAP PROCESSED BY
ADDRES
❑ I am exempt under Sec. of the L.A.Co. - 2 e9O BK PG ��G�2-G- a
CITY TEL.NO. O
Plumbing Code and/or Sec. of the STATE LIC. — FINAL VALIDATION U
LICENSE NO. ! CLASS DATE
B. 8 P. Code for the following reason NO. DESCRIPTION OF WORK FEE (�v Z
HOUSE SEWER CONNECTING TO FINAL 0
D e PUBLIC SEWER1• BY V
SEPTIC TANK SEEPAGE PIT OR W
Signature
PITS AND OR DRAINFIELD d
HOUSE SEWER CONNECTING TO
NER-BUILDER DECL TION PRIVATE DISPOSAL SYSTEM ® ?
hereby affirm that I am exe ptfro e Contractor's License CONNECT ADDITIONAL BLDG OR
Law for the following reason cton 7031.5, Buisness and Pro- WORK TO HOUSE SEWER -
fessiOns Code)' OVERFLOW SEEPAGE PIT DRAINFIELD 'F j'•
EXTN,CESSPOOL,DRYWELL,MANHOLE
❑ 1, 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 sale (Section 7044, Business
and Professions Code).
�=.
❑ I, as owner of the property, am exclusively contracting with Permit $ y'�(=`s?._ •_ ••-�'--I"
licensed contractors to construct the project (Section 7044, OWNERS .iN»r•; ;• �-
Business and Professions Code). AUTHORIZATION TOTAL FEE
HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMEDISEWER
TO
CONSTRUCTION LENDING AGENCY ® ,U
I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUfor the performance of the work for which this permit is
slued (Sec. 3097, Civ. C.). SIGNED THISDAY OF r;
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 ulating Plumbing and Sewers,
and hereby authoz r tives of this County to enter
upon the above- one pro rty for inspection purposes.
S nature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE