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HomeMy Public PortalAbout10819 FREER ST_Sewer__ WORKERS'COMPENSATION DECLARATION d'hereby affirm that I have a certificate of consent to self 92-0002 DPW 3/87 + CE 808 D �7 OT insure, or a certificate of Workers'Compensation Insurance, or GI'IIS CE BOB APPLICATION FOR PERMIT a certified copy thereof(Sec. 3800, lab C.) / Policy No.la Company V , ©s Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL Certified copy is filed with the county building ins ection COUNTY OF LOS ANGELES BUILDING AND SAFETY r depa tme t P Date Applicant ��I �21/ FOR APPLICANT TO FILL IN CONNECTION DATA CER IFICATE OF EXEMPTION FROM WORKERS' BUILDING COMPENSATION INSURANCE ADDRESS STATION DEPTH (This section need not be completed if the work involved by the rn MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) LOCALITY LOWER NEA I certify that in the performance of the work for which this CROSSSST TYPE OF CONNECTION LENGTH FROM Y. CURB P.L. M.L.TO P.L. permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. j� P.C.NO. OWNER e b r� CO.IMP.NO. JOB NO. MAIL J� y/' J x TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS VL V NOTICE TO APPLICANT: If, after makingthis Certificate of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE CITY TEL.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 deemed revoked. BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO.OF 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. Xr, CONTRACTOR / 'CONNECTION CHARGE FEE License Ni U LiC.CIaSS ADDRESS )- REIMBURSEMENT FEE O C DISTRICT NO. GROUP MAP PROCESSED BY Contractor Date CITY � TEL.NO. //r� BK PG ❑ I am exempt under Sec. of the L.A.Co. LICENSE No. CLASS J.� O SCR Plumbing Code and/or Sec. of the NO. DEIPTION OF WORK FEE -FINAL U HOUSE SEWER CONNECTING TO /JI/ DATE VALIDATION LU B. & P. Code for the following reason PUBLIC SEWER O� f — IL 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 SEEPAGE PIT,I hereby affirm that I am exempt from the Contractor's License EO TNVERFLOCESSPOOL,DRYWDRAMANHOLE Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE 11 F fessions Code): SEWER OR DISPOSAL SYSTEM ❑ I,as owner of the property, or my employees with wages as Nr'C 4 :xF their sole compensation, will do the work and the structure _ is not intended or offered for sale (Section 7044, Business .;t i jnd Professions Code). OWNER'S PermiT $ Eya __ _ as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE ( licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO i i'([F-t� b 4 Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_ e for the performance of the work for which this permit is OWNER OR issued (Sec. 3097, Civ C.). i OWNERS AGENT Lender's Name ADDRESS Lender's Address li 3E— ) !1 t 4,r N 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 pro rty f r nspection pyr ses. C Signature of Permitt l Date / SEE REVERSE FOR EXPLANATORY LANGUAGE