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HomeMy Public PortalAbout10815 FREER ST_Sewer__ WORKERS'COMPENSATION DECLARATION I 'hereby affirm that I have a certificate of consent to self 92-0002 DPW 3/B7 insure, or a certificate of Workers'Compensation Insurance, or CE 808 D C/ LI IS a certified y Thereof (Sec. 3800, L b C.) CE 808 gpPLICATION FOR PERMIT Policy No. company -YLIP ®S Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY dep r ate tme Applicant �c / ,/�` FOR APPLICANT TO FILL IN CONNECTION DATA CE TI ICATE OF EXEMPTION FROM WORKERS' BUILDING _4 /J £ COMPENSATION INSURANCE ADDRESS ©O �G G�,� STATION O 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 LOWER I certify that in the performance of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROM CROSS ST. Y. CURB P.L. M.L.TO P.I. permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. P.C.NO. OWNER / CO.IMP.NO. JOB NO. MAIL r �� TRUNK PERMIT NO, ROAD PERMIT NO. Date Applicant ADDRESS W h I. n NOTICE TO APPLICANT: If, after makingThis Certificate Of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE CITY AycAAoalTEL.NO. Exemption, you should become subject to the Workers' LEGAL /J Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemedy revoked. BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO.SIZE OF LOT Now ON Lor I hereby affirm that I am licensed under provisions of Chapter USE OF 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES ness and Professions Code, and my license is in f II force and effect. 'V1IT CONTRACTOR CONNECTION CHARGE FEE License Number `� Lic.Class �, EIMBURSEMENT FEE d ADDRESS 0 � I R RICT NO. GROUP MAP PROCESSED BY (,) Contractor DIST ^ d n.. Date CITY �'�✓ TEL.NO. / BK PG Z STATE LIC/ 0 ❑ I am exempt under Sec. Of the L.A.CO. LICENSE NO. fi C ASS 3Of Plumbing Code and/or Sec. of The NO. DESCRIPTION OFIWORK FEE FINAL VALIDATION � HOUSE SEWER CONNECTING TO DATE Q B. & P. Code for the following reason PUBLIC SEWER �— ! N SEPTIC TANK,SEEPAGE PIT OR FINAL W PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE 6j? Law for the following reason (Secton 7031.5, BUlsness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): _ SEWER OR DISPOSAL SYSTEM ❑ I,as owner of the property, or my employees with wages as their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business 1 ' and Professions Code). OWNERS Permit $ �3 8p .LIEla: I as owner of the property, am exclusively contracting with AUTHORIZATION I TOTAL FEE Q ,;,ft"" 5 r' m 5413 licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TOw+i Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. 111EICY rl_i CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_ C, :"(-((•(y;E for the performance of the work for which this permit is OWNER issued (Sec. 3097, C�Vjj•�C.)/ n ,/ OWNERS AGENT ADDRESS Lender's Name s,%d0 `_ 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 County ordinances and State laws regulating Plumbing and Sewers, and hereby authorize representatives of this County to enter upon f e above-mentioned p perty f inspection 7rposes. /v Signature of P ittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE