HomeMy Public PortalAbout5121 FARAGO AVE_Sewer__ WORKERS' COMPENSATION DECLARATION
I_herb'''offirm that I have a certificate of consent to self 766642 DPW 6/89
Insure, or 8 certificate f Workers' Compensationgli,ance, or 76A642Da certified rf c. 3800, ) J APPLICATI®fel F®R PERMIT
Policy No� mpany �� � o
ElCertifiedcopy is hereby furnished. SEWER - SEWAGE DISPOSAL
Certified copy is filed with the county ng inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
dwrotm nt. �
Dat pplicont FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION F OM W RKERS' BUILDING A
COMPENSATION I URAN ADDRESSSTATION DEPTH
(This section need not be complet e 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. v 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 Lows. 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 CHARGES
ness and Professions Code, and my'license is in full force and ADDRESS 16 T
effect. _y/��-/yeJ�/ CITY ` C TEL.I�/131
CONNECTION CHARGE FEE
License Number , �L+TC.Class v� REIMBURSEMENT FEE
CONTRACTOR !
Contractor mite DISTRICT NO GROUP MAP PROCESSED BY
/ ADDRES l n� BK PG }
❑ I am exempt under Sec. of the L.A. o. (/ d
CITYkz' Zt— TEL.NO. � O
Plumbing Code and/or Sec. of rhe STATE LIC. FINAL 0
LICENSE NO. ( CLASS =d
DATE }}�� VALIDATION Z
B. 8 P. Code for the following re NO. DESCRIPTION F WORK FEE !V✓1-' Q
HOUSE SEWER CONNECTING TO a,-1T- FINAL
Dat PUBLIC SEWER f BY W
SEPTIC TANK SEEPAGE PIT OR d
Signature PRS AND OR DRAINFIELD N
NER-BUILDER DEC ARAT HOUSE SEWER CONNECTING TO ® Z
�� PRIVATE DISPOSAL SYSTEM (ry',•':.' „-`
I hereby affirm that I am exempt f e 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
) E%iN,CESSPOOL.DRVWELL,IL,MANHOLE
❑ I, as owner of the property, or my employees with wages as ALTER,REPAIR OR ABANDON HOUSE L`
SEWER OR DISPOSAL SYSTEM
their sole compensation, will do the work and the structure �-w
is not intended or offered for sale (Section 7044, Business
and Professions Code).
❑ t, as owner of the property, am exclusively contracting with OWNER'S Permit $ , t -
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.F�i { ;-
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
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 lows regulating Plumbing and Sewers,
and herebyauthorize resentatives of this County to enter
upon the ab�.e-m roperty for inspection purposes,
gnature of Permittee Dae SEE REVERSE FOR EXPLANATORY LANGUAGE