HomeMy Public PortalAbout10817 FREER ST_Sewer__ • WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self 92-0002 DPW 3/87
insure, or a certificate of Workers'Compensation Insurance, or 76A642D
a Policy
copy thereof-(Sec.omp 3800, LC..)[14 0"g y �CESBOB APPLICATION FOR PERMIT
Pglic Na. ham an SEWER - SEWAGE DISPOSAL
Certified copy is hereby furnished.
Certified copy is filed with the county building ins ection COUNTY OF LOS ANGELES BUILDING AND SAFETY
dep rt nt.i '�,
Date Applicant FOR APPLICANT TO FILL IN O CTION DATA
&RTI KATE OF EXEMPTION FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDRESS e 6Pj7 STATION DEPTH
(This section need not be completed if the work involved by the LOCALTY MANHOLE REFERENCE UPPER
I
permit is for one hundred dollars ($100)or less.) LOWER
I certify e that in the of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROM
performance .
permit is issued, I shall not employ any person in any manner CROSS STY. CURB P.L. MA.TO P.L.
so as to become subject to the Workers' Compensation Laws. i i P.C.NO.
OWNER CO.IMP.NO. JOB NO.
MAIL ��e ,. TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS ]V�
NOTICE TO APPLICANT: If, after making CITY this Certificate Of t7 i/,f AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
,/Y L)
Exemption, you should become subject to the Workers' LEGAL TEL.NO.
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 deemed
revoked. BLOCK TRACT 7 STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO. F BLDGS. PERMIT NO.
SIZE OF LOT NOW ON LOT
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 full force and
effect. CONTRACTOR CONNECTION CHARGE FEE
License Number i 65M Lic.Class 6 ADDRESSREIMBURSEMENT FEE 0.
Contractor - 5 Date CIT TEL.NO
DISTRICT NO. GROUP MAP PROCESSED BY V
BK PG �
I
El STATE
I am exempt under Sec. of the L.A.Co. STATELICENSE No. W aass Of 3 0
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF ORK FEE FINAL U
HOUSE SEWER CONNECTING TODATE VALIDATION LU
—
B. & P. Code for the following reason I PUBLIC SEWER Z
SEPTIC TANK,SEEPAGE PIT OR In
PITS AND/OR DRAINFIELD FINAL
Date HOUSE SEWER CONNECTING TO
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
Law for the following reason (Sectors 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSES 5
fessions Code): SEWER OR DISPOSAL SYSTEM .
❑ I, as owner of the property, or my employees with wages as dJ` r d
their sole compensation, will do the work and the structure ` - 1-)
is not intended or offered for sale (Section 7044, Business -•
and Professions Code). OWNER'S Permit g - - ,-.
1
I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE a
licensed contractors 10 construct the project (Section 7044, Al
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO 'L-;i rIL-•
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. Ir-•5i .,,,„,
CONSTRUCTION LENDING AGENCY 1L-;}`• =L"i.y+=
I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_
for the performance of the work for which this permit is OWNER OR =•5LH€,= si_=,.,
issued (Sec. 3097, Civ.�C. '. OWNERS AGENT
Lender's Name ADDRESS - „. _
Lender's Address J�J try
979 6
!i (1—i Ei_I i y i;
I certify that I have reod 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 th above-mentioned operty for Inspectio purposes.
Signature of PerWttee Date SEE REVERSE FOR EXPLANATORY LANGUAGE