HomeMy Public PortalAbout9842 FLAHERTY ST_Sewer__ WORKERS' COMPENSATION DECLARATION 20-0051
I"hgrgby offire that I hoveo certificate of consent to self 76A642DPwBt89
Insufe, or a certlficrne of Workers'Compensation Insurance, or 76A642D
a certlfled copy thereof (Sec. 3800, Lab C.) APPLICATION FOR PERMIT
Pollay No. Company S7 -7Z-:: -yn7�
❑ Certified copy s3hereby furnished. SEWER - SEWAGE DISPOSAL
❑ Certified copy'is filed with the c my building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department. 'In
Date?—)t`/-9J Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EX P ION F OM WORKERS' BUILDING
COMPENSATION INSURANCE ADDRESS (J � STATION ;"-/ *7 DEPTH
(This section need not be completed if the work involved by the MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY 3 f D LOWER
NEAREST TYPE OF CONN ON LENGTH FROM y
I certify that in the performance of the work for which this CROSS ST. v CURB- P L M L TO P L
permit is issued, 1 shall not employ any person in any manner LEGAL
PC NO
so as to become subject to the Workers' Compensation Laws. DESCRIPTION LOT NO, CO IMP No tos No
Date Applicant BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
NOTICE TO APPLICANT: If, after makingthis Certificate Of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
MAP BOOK PAGE ;,A PARCEL ��
Exemption, you should become subject to the Workers' No.OF BLDGS.
Compensation provisions of the labor code, you must forthwith SIZE OF LOT NOW ON LOT HWY OR Sr WIDENING
comply with such provisions or this permit shall be deemed USE OF
revoked. BUILDINGS STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION PERMIT No
1 hereby affirm that I am licensed under provisions of Chapter OWNER
9 (commencing with Section 7000) of Division 3 of the Busi- MAIL CHARGES
ness and Professions Code, and m,/license is in full force and ADORES
effect. CITY TEL.NO. CONNECTION CHARGE FEE
License Number Sze$y0 lic. Class /3
CONTRACTOR REIMBURSEMENT FEE
Contractor �2-�N 1?
AZ I4kDate 7—f y YJ'j DISTRICT NO GROUP MAP PROCESSED BY
ADDRESS BK PG
�9 }
Elam exempt under Sec. of the L.A.Co. CITY TEL.No. ��� -!3 �(g �'� O
PlumbingCodd/ Sec. f the STATE LIC. FINAL
e and/or o
LICENSE NO. CLASS DATE r"�i—� VALIDATION
B. & P. Code for the following reason NO. DESCRIPTION OF WORK FEE O
HOUSE SEWER CONNECTING TO FINAL
Date PUBLIC SEWER BY V
SEPTIC TANK SEEPAGE PIT OR W
a
SlgnOtUr Ol/d/Ls (� PITS AND OR DRAINFIELD N
HOUSE SEWER CONNECTING TO
OWNE -BUILDER DEC ARATION PRIVATE DISPOSAL SYSTEM
I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR _
Law for the following reason (Secton 7031.5, Buisness and Pro- WORK To HOUSE SEWER yi
OVERFLOW SEEPAGE PIT.DRAINFIELD
feSSIOnS Code): ExTN,CESSPOOL.DRYWELL.MANHOLE i p ;-TaM
❑ I, as owner of the property,or my employees with wages as ALTER.REPAIR OR ABANDON HOUSESEWER OR DISPOSAL SYSTEM -
their sole compensation, will do the work and the structure ?�s3
is not intended or offered for sale (Section 7044, Business i I ''-
and Professions Code). :t-=
❑ 1, as owner of the property, am exclusively contracting with Permit $ �j Q 1 OTA!
licensed contractors to construct the project (Section 7044, OWNER'S
71 = 10
Business and Professions Code). AUTHORIZATION FTOTAL FEE �, Q CHECK
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMEW CONTRACTOR TO -^
I hereby affirm that there is a construction lending agency
CONNECT THE ABOVE DESCRIBED EXISTING DWELLING ro THE Pueuc SewER , '•.:I'IANGE "•!€
for the performance of the work for which this permit Is
issued (Sec. 3097, Civ. C.) SIGNED THIS DAY OF 19_
Lender's Na
e !may D(/J/x/oyZ-" OWNERSO
m ,CQ
AGENT
Lender's Address ADDRESS I a H 11:
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 ove-mentioned property for inspection purposes.
7 .
ignai re of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE