HomeMy Public PortalAbout8814 GARIBALDI AVE_Sewer__ WD !C RS'COMPENSATION DECLARATION 7EA442D
CE 808 (2-80) APPLICATION FOR PERMIT {I
I hereby affirm that I have a certiflrate of consent to self SEWER-SEWAGE DISPOSAL
Iruure, or a certiflelte of Workers'Compenution-Insurance,or
a,certinod copy thereof(Sec. 3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company '
FOR APPLICANT TO FILL IN CONNECTION DATA
El Certlfled copy is hereby furnished.
BUILDING STATION DEPTH
❑ Certifled copy is filed with the county building Inspection ADDRESS
UPPER
department. LOCALITY MANHOLE REFERENCE
LOWER
Date Applicant NEARESTTYPE OF CONNECTION LENGTH FROM
CERTIFICATE OF EXEMPTION FROM WORKERS' cRoas ■T. Y. CURP.L. M.L. TO P.L.
COMPENSATION INSURANCE P.C. No.
OWNER f of
CO. IMF. NO. JOB NO. }
ff section need not be comppleted If the work Invohed MAIL a
by the permit is for 011e hundred dollars (=100) or leas.) ADDRESS / ' TRUNK PERMIT NO. ROAD PERMIT NO.
TEL. NO. 8/1
/�P PIDAVIT WANSR CAp@T RECORD.INsm.NO. DAT.
. CITY
I certify that In the performance of the work for which this LEGA
permit Is issued, I shall not em loy any person in any manner DKscPurnoPn LOT NO.
HWM. OR /T. WIDENING
to as to b m subject to km' mpensation Laws.
■LOCK TRACT STATE ENCROACHMENT tL
Dat Applicant NO. of SLOG/. PERMIT NO. 05
NOT E APPLICANT: If, after me g this Certificate of SIZE OF LOT NOW ON LOT Z
Ex ption, you should become subject to the Worker' UsE of crlwwaE■
Compensation provisions of the Labor Code, you mutt forth- BUILDINGS
with comply with such provisions or this permit shall be CONNECTION CHARGE FEE
deemed revoked. CONTRACTOR
LICENSED CONTRACTORS DECLAMATION ADORE■ RFTRI UNo. GR T PEE
I hereby affirm that I am licensed under provisions of Chppter DIKTRICT NO. owouP YAP PROOK KD..
9 (commencfing with Section 7000) of DlvWon 3 of the Busl- CITY TEL. NoFl- ■K Pa
news and ProfeasiopnsL
effect.
s Code, and toy license in full force and STATE // LIC.
LICENSE NO. / _CLASS
�y O
NO. DQEC IPTION 9F WORT( FEE
License Nu r�Lic,Clan■ ✓� H..D,:�Ic KIEKR O""/crlNa TO FINADATE 2 —Z 2 VALIDATION
DATE J
■KPnC TANK,■KKPACK PIT OR
Contract DatPITS ANDloR PRAINPIKLD FINAL
HOUKK KKWKR CONNECTING TO BY
F1PRIVATZ OIK►OSAL■YSTKY
I am exempt from the 1lcensin: ulrementa as I am ■
licensed architect or a registered professional engineer WOnK To I,ouKK�KKSFKR`D■ OR
acting in my -professional capacity (Section 7051, Bus- Ov KRFLOW■KKPACK PIT,DRAINPIKLD _
mess and Professions Code). KICTN.,cK//POOL,DRYWSLL,MANHOLE
ALTER,REPAIR OR ASANDOR HOUSE
f K IEKR OR DISPOSAL■T STKMF
Lic.or Reg.No. Data
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's OWJER'S Permit f
License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE5 2 0.4 A
news and Professions Code):
1 HAVK AT THIS OATS A CONTRACT WITH THK HEwSIN YSD con- # O O O'O 1 0
TRACTOR❑ TO CONNKCT THE AEOVK OKSCRIEKD jAIKT1NC OWKLLIN■ ,I, as owner of the property, will do the work and the TO THE PU■LIO ■KWKR.
structure Is not intended or offered for sale (Section 1 .- - 17.50
\`�^' SIGNED THIS DAY OR t0
7044,Bustnaw and Professions Code). OWNKR OR 1 7,506
OWNKR■ACKNT .O O'O p
CONSTRUCTION LENDING AGENCY ADDRKK■ Q � 1 1 —8:1
I hereby efflrm'that there Is a construction lending agency
for the performance of the work for which this permit is
Issued (Sec. 3097,Civ.C.).
Lender's Name
Lender's Address
I certify that I have read thh application and state that the
above information Is correct.I agree to comply with all County
ordlhances and State laws regulating Plumbing *ad Sewers,
_jLwLhereby authorize representatives of thls County to enter
up he abovo-men party for Inspection purpo
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature o ttee