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WORKERS COMPENSATION DECLARATION D
CE 808 (2 80) APPLICATION FOR PERMIT
CE 808
I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL
Insure or a certificate of Workers Com ensation I nc or
a certified�o y thereof Sec 3800 ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No " �
FOR APPLICANT TO FILL IN CONNECTION DATA
El Certified copy is hereby fur
l';'��/ BUILDING STATION L60 DEPTH
Certified copy is filed with the county building Inspection ADDRESS E � 7 PPER
department LOCALITY e p MANHOLE REFERENCE / O LOWER
Date Applicant NEAREST TYPE OFTION LENGTH FROM
CERTIFICATE OF EXEMPTION FROM WORKERS CROSS ST L Y cUR P L M L TO P L
COMPENSATION INSURANCE P C NO
OWNER CO IMP NO JOB NO
MAIL
(This section need not be completed if the work involved ADDRESS TRUNK PERMIT NO ROAD PERMIT NO >_by the permit is for one hundred dollars ($100) or less) AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE CL
CITY TEL NO �T� O
1 certify that In the performance of the work for which this LEGAL
permit is issued I shall not employ any person in any manner DESCRIPTION LOT NO HWY OR ST WIDENING tr
so as to become subject to the Workers Compensation Laws Q
BLOCK TRACT STATE ENCROACHMENT
Date Applicant NO OF BLDGS PERMIVIO 1 (�
SIZE OF LOT NOW ON LOT W
NOTICE TO APPLICANT If after making this Certificate of CL
Exemption you should become subject to the Workers USE OF Cn
Compensation provisions of the Labor Code you must forth BUILDINGS CHARGES Z
with comply with such provisions or this permit shall beFL-0 yn 13 1 ` ' CONNECTION CHARGE FEE
deemed revoked CONTRACTOR fV
LICENSED CONTRACTORS DECLARATION ADDRESS M v
CA CL— REIMBURSEMENT FEE
I hereby affi m that I am licensed under provisions of Chapter � fT V DISTRICT NO GROUP MAP PROCE sED BY
9 (commencing with Section 7000) of Division 3 of the Busi clTv CjAagZ6rEL No L,L7�� BK
ness and Professions Code and my license is in full force and STATE .� ' LIC C-34
effect LICENSE NO CLASS
NO DESCRIPTION OF WORK FEE
rr r_ HOUSE SEWER CONNECTING TO FINAL VALIDATION
License Number3 }2 LIc Class C-30 PUBLIC SEWER DATE
SEPTIC TANK SEEPAGE PIT OR
Contractor Date PITS AND/OR DRAINFIELO
�- HOUSE SEWER CONNECTING TO FINAL
F-1 PRIVATE DIaPOSAL SYSTEM BY
I am exempt from the licensing requirements as I am a
CONNECT ADDITIONAL BLDG OR
licensed architect or a registered professional engineer WORK TO HOUSE SEWER /y
acting in my professional capacity (Section 7051 Bus OVERFLOW SEEPAGE PIT GRAINFIELD
(nets and Professions Code) EXTN CESSPOOL D—WELL MANHOLE -/\
ALTER REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
Lic or Reg No Date
HOME OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors OWNERS Permit S B
License Law for the following reason (Section 7031 5 Busi AUTHORIZATION TOTAL FEE 1
ness and Professions Code)
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON
F1TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING 9 4 4 a 3 A
I as owner of the property will do the work and the TO THE PUBLIC SEWER
structure Is not Intended or offered for sale (Section SIGNED THIS DAY OF is # o o D D 0
7044 Business and Professions Code) OWNER GR
OWNERS AGENT
CONSTRUCTION LENDING AGENCY 2 0 0 1 8.00
I hereby affirm that mADDRESSere Is a construction lending agency I=
for the performance of the work for which this permit is o 0 0 1 a 0 0,X0
issued (Sec 3097 Civ C )
Lender s Name 0 3, 19-81
Lender s Address
I certify that i have read this application and state that the
above information Is correct I agree to comply with all Courty
ordinances and State laws regulating Plu burg and Sewers
and hereby authorize representatives of is County to enter
upon the abo mentioned p erty o Spection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
.c -f9-$l
V19 nature of Permittee4V Date