HomeMy Public PortalAbout9006 GARIBALDI AVE_Sewer__ WORKERS' COMPENSATION DECLARATION t�
I hereby affirm that I have a certificate of consent to self 2aom T���
Insure, or a certificate of Workers' Compensation Insurance, ori
a certified c her of (sec. 3800 Lab�. APPLICATION FOR PERMIT
Policy IGc�ompany
❑ Certified copy is hereby furrdshed. SEWER - SEWAGE DISPOSAL
❑ Cbrtifled•copy is filed with the county building inspecj(pn COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
,CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE AADDOFEN srArtoN DEPTH
(?his section need not be completed If the work Involved by the MAt+toLE REFERENCE UPPER
permit Is for one hundred dollars ($100)or leu.) LOCALITY
NEAREST TYPE Of CONNECTION LENGTH FROM
I certify that In the performance of the work for which this CFX)W ST. Y CURD PL ML TOP L
permit Is issued, 1 shall not employ any person In any manner LEGAL PC NO
so as to become subject to the Workers' Compensation Laws. DEDCFIPT1oN LOT HO. Co LW NO "+EO
Date Appl Kant BLOCK TAT TRUNK PERAUT NO ROAD PERMIT NO
NOTICE TO APPLICANT: If, after making this Certificare of PAGE X914 PA.0-0� AffDAvrT WAR EASEMENT RECORD INSrR NO DATE
Exemption, you should become subject to the Worker' NO OF BLDOS.
Compensation provisions of the Labor code, you must forthwith SLZE OF LOY NOW ON LOT HWY OR ST WIDEMNG
comply with such provisions or this permit shall be deemed USE OF
revoked. BLALDtN<IS STAR BJCROACHA%ENT
LICENSED CONTRACTORS DECLARATION PERMT No
I hereby affirm t4gt i am licensed under provislont of Chapter
9 (commencing with Section 7000) of Division 3 of the Busi- � GCHARM
nese and.Professions Code, and,my license Is In full force and
effect. CITY A TEL No. z— CONNECTION CTtARGE I$
License Number ` Lic.Clou REUWBURSEMENT FEE
11 CD NTAACTOR
Contractor�" ♦,`--� �OriY-Date DISTRICT NO GROUP AM,P PROCESSED AY
ADDIRM t BK PG
❑ I am exempt under Sec. of-the L.A.Co. ter D� 3
Plumbing Code and/or Sec. of the STATE INK
LJC`EN P N� aA� DATE LIDATION
B. 8 P. Code for the following reason NO, D85C%PT10A Of
woElk F� — p
Date / PU911C EWERSEPTiC CONNECTING TO FNAL
BY
A{GT.T
TALL( SEEPAGE PIT CIR
Signature PITS Ann OR DRAJWIE[D 33 71
OWNER-BUILDER DECLARATION HOUSE SEWER CON PRNA YSTEMG To , y� ITEJ�
r
I hereby affirm that I am exempHrom the Contractor's License cor+XECT 1KXC4L&_DG OR
Law for the following reason (Secton 7031.5, Buisness and Pro- WORK TO HOUSE SEWER '} /JTAL �y
OVERFLOW SEEPAGE PIT DRAYNFELD TO7 1 _ 11D
fesslOns Code): ExTN CESSPOOL DRYWELL MANHOLE
❑ I,as owner of the property, or my employees with wages as µTER.REPA'R OR ABANDor.L HpvSE UL{l 71.10
their sole compensation, will do the work and the structure SEWER OR DISPOSAL SYSTEM .00Is not Intended or offered for sale (Section 70.", Business
and Professions Code).
❑ I, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Section 7CL", OWNERS Permit i 0000-L'1001 7/25/94
Business and Professions Code). AUTHORIZAT110141 TOTAL FEE /O 61 1AM �CI�
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED C RACTOR TO ,
I hereby affirm that there Is a construction lending agency CONNECT THE AeovE DE SCRI PED E X LST I NG DWE LL I NG TO THE PUeI IC SEWER
for the performance of the work for which this permit- Is
issued (Sec. 3097, Civ. C.). SECtVED DAY OF 19L
OWNER OR
Lender's Name OWNERS AGENT
Lender's Address ADoaEssf
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
n the above-mentioned property for Inspection purposes.
gnoture of Permittee Date / SEE REVERSE FORlXPLANATORY LANGUAGE