HomeMy Public PortalAbout10679 FREER ST_Sewer__ WORKERS'COMPENSATION DECLARATION 76A642D , APPLICATION FOR PERMIT
C� 808 (2190)
I hereby affirm that I have a certificate of consent to Self' SEWER—SEWAGE DISPOSAL
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,L . C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Po(Certified
y No. Company
copy is hereby furnished., FORAPPLICANT TO FILL IN CONNECTION DATA
�/
/�f �I� �� BUILDING STATION �7 DEPTH /
Certi iT ed
copy isi�ed�itTthe county building inspection ADDRESS �
department. / MANHOLE REFERENCE
LOCALITY 4 • ♦ C�� �V 40-�M�R
Date Applicant NEAREST TYPE OF CONNECT LENGTH FROM
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. Y. cURB P.L. M.L. TO P L.
COMPENSATION INSURANCEP.C. NO.
OWNER CO. IMP. NO. JOB NO. }
MAIL 0
(This SOCtIOn need not be completed if the work involved ADDRESS 10 TRUNK PERMIT NO. ROAD PERMIT NO. 0
by the permit is for one hundred dollars ($100) or less.) AFFIDAVIT I WAIVER EASEMENT RECORD, INSTR. NO GATE
CITY TEL. NO.
I certify that in the performance of the work for which this LEGAL' Ir
permit is issued, I shall not employ any person in any manner DESCRIPTION LOT NO. /_3 0
HW
O. HW Y, OR Sl'. WIDENING 0
so as to become subject to the Workers' Compensation Laws. U
BLOCK TRACT STATE ENCROACHMENT W
Date Applicant NO. OF BLDGS. PER IT NO.SIZE OF LOT NOW ON LOT
IL
N
NOTICE TO APPLICANT: If, after making this Certificate of „< <,G � � Z
Exemption, you should become subject to the Workers' USE OF CHARGES
Compensation provisions of the Labor Code, you must forth- BUILDINGS ) y
with comply with such provisions or this permit shall be CONNECTION CHARGE FEE
deemed revoked. CONTRACTOR +
3.� ®• (/) REIMBURSEMENT FEE
LICENSED CONTRACTORS DECLARATION 'ADDRESS '(,�
I hereby affirm that I am licensed under provisions of Chapter `w DISTRICT NO. GROUP MAP PROCES5ED BY
9 (commencing with Section 7000) of Division 3'of the Busi- clry 94 �r[ TEL. No.
ness and Professions Code, and my license is in full force and STATE LIC. �� aG� 1—
effect. LICENSE NO. CLASS '�vV
NO.T, DESCRIPTION OF WORK FEEz
HOUsE SEWER CONNECTING TO FINAL / 'Q� VALIDATION
License Num r Lie. Class PUBLIC SEWER DATE /`C/— QQ
SEPTIC TANK,SEEPAGE PIT OR
Contractop
PITS ANO/OR DRAINFIELD FINAL
HOUSE SEWER CONNECTING TO
..y PRIVATE DISPOSAL SYSTEM BY
U I am exempt from the licensing requirements as I am a 4
CONNECT ADDITIONAL BLDG. OR
licensed architect or a registered professional engineer WORK TO HOUSE SEWER
acting in my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT, DRAINFIELD
iness and Professions Code). EXTN.,CESSPOOL, DRYWELL, MANHOLE
ALTER, REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
Lie.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION _
I hereby affirm that I am exempt from the Contractor's OWNER'S Permit S 3U
License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE �J zf4 4 1,2 A
ness and Professions Code) I HAVE AT THIS DATE A NTRACT WITH T E HEREIN NAMED N-
TRACTOR TO CONNECT ABOVE DESCRI ED EXISTING OWE G O
I, as owner of the property, will do ttie work and the TO THE PUBLIC SEW A�^ # o�o 1.
structure is not intended or offered for sale (Section SIGNED THIS v of
7044, Business and Professions Code). OWNER OR 2'O ° 2350
OWNERS AGEN`T
CONSTRUCTION LENDING AGENCY ADDRESS ! 7 0 o yo 2 3 5 Q
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is 0•� 1 8.-8 2
issued(Sec. 3097,Civ.C.).
Lender's Name
Lender's Address
0
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 a laws regulating Plumb' g and Sewers,
and hereby a i ze representativ of this o ty to enter
upon thea entioned pro rty r nspe purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date