HomeMy Public PortalAbout5489 GOLDEN WEST AVE_Sewer__ WORKERS' COMPENSATION DECLARATION 200051 DPW 6189 U
I hereby affirm that I have a certificate of consent to self
Insure, or a certificate of Workers' Compensation Insurance, or 76A642D
a certified copy thereof (Sec 3800, Lab C ) APPLICATION FOR PERMIT
Policy No Company
❑ Certified copy is hereby furnished SEINER - SEWAGE DISPOSAL
❑ Certified copy is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department
Dote Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING {—
COMPENSATION INSURANCE ADDRESS w �N X71 y C( STATION 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
NEAREST TYPE OF CONNECT,ON -.+� LENGTH FROM
I certify that In the performance of the work for which this CROSS ST Y CURB' P L M L TO P L
permit Is Issued, I shall not employ any person In any manner LEGAL
sops to become subject to the Workers' Compensation Laws DESCRIPTION LOT NO 5 P c No
CO IMP NO JOB NO
BLOCK TRACT I '3 S�s TRUNK PERMIT NO ROAD PERMIT NO
Date Applicant
NOTICE TO APPLICANT If, after making this Certificate Of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO. DATE
g MAPBOOK PAGE PARCEL
Exemption, you should become subject to the Workers' NO OFBLDGS
Compensation provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT HWY OR ST WIDENING
comply with such provisions or this permit shall be deemed USE OF
revoked BUILDINGS STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION OWNER 1"�`/0 yn p p 1N�� dol' PERMIT NO
I hereby affirm that I am licensed under provisions of Chapter
UO� IQ(�
9 (commencing with Section 7000) of Division 3 of the Busi- MAIL rC� � �,
,13 CHARGES
Hess and Professions Code, and my ADDRESS license is In full force and _Q y_ Q
effect CITY L TEL NO S �5/� CONNECTION CHARGE FEE
License Number Lic Class REIMBURSEMENT FEE
CONTRACTOR
Contractor Date DISTRICT NO GROUP MAP PROCESSED BY
ADDRESS BK PG
❑ I am exempt under Sec of the L A Co DO ✓1 a
CITY TEL NO O
Plumbing Code and/or Sec of the STATE LIC FINAL �/ n U
LICENSE NO CLASS DATE
)` l 4 VALIDATION Z
B 8 P Code for the following reason NO DESCRIPTION OF WORK FEE (� `� Q
HOUSE SEWER CONNECTING TO FINAL (-
Date PUBLIC SEWER BY LU
SEPTIC TANK SEEPAGE PIT OR 0-
Signature PITS AND OR DRAINFIELD W
OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING TO Poo. y
PRIVATE DISPOSAL SYSTEM (�
I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR 1
Law for the following reason (Secton 7031 5, Bulsness and Pro- WORK TO HOUSE SEWER JJ� A -
fessiOns Code OVERFLOW SEEPAGE PIT DRAINFIELD A1•CT.1'
EXTN CESSPOOL DRYWELL MANHOLE
Q2_1, as owner of theproperty, Or m employees with wages as ALTER REPAIR OR ABANDON HOUSE 7e�1
y g SEWER OR DISPOSAL SYSTEM r 33.03
their sole compensation, will do the work and the structure � ITEMS
is not Intended or offered-for sale (Section 7044, Business
and Professions Code) TOTAL 5
❑ I, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Section 7044, OWNERS Permit $ICONfIRACTOR
CHECK 57.20
Business and Professions Code) AUTHORIZATION TOTAL FEEC�i �i� e00
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A coNTRACT WITH THE HEREIN NAMEI hereby affirm that there IS a construction lending agency' CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE Pfor the performance of the work for which this permit Is issued (Sec 3097, Civ C ) SIGNED THIS D Y OF f1r-SCI _ �1 4/ 1/96
OWNER OR UVV
Lender's Name OWNERS AGENT FI
p` 1�C /�M if10p0L
.5.1 N t Q
Lender's Address ADDR ss
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
upont e above-mentioned property for inspection purposes
XSignature of 136rmittee E17e SEE REVERSE FOR EXPLANATORY LANGUAGE