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HomeMy Public PortalAbout5528 GOLDEN WEST AVE_Sewer__ WORKERS'COMPENSATION DECLARATION D CE 808 (2-80) APPLICATION FOR PERMIT CE 808 I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL in e, or a certificate of Workers'Com sation Insurance, a ed copy thereof Sec. 3soo, L n COUNTY OF LOS ANGELES BUILDING AND SAFETY P i O. Company —�) ❑ C %� .� FOR APPLICAN TO FILL IN CONNECTION DATA �rtlfied co y is hereby fur fished. BUILDING � ^ � � � STATION • C DEPTH ADDRESS l Certi d c p is filed wit e C ty b iD ms ction UPPER d e OCALITY MANHOLE REFERENCE Date Applican NEAREST TYPE OF C CTION LENGTH FROM C TI CATE OF EXEMPTION FROM r .l cRoss ST. Y. CURB P.L. M.L. TOP,L. COMPENSATION INSURANCE P.C. OWNER CO. IMP. NO. JOB NO. MAIL CL > (This section need not be completed if the Qwork involved ADDRE S TRUNK PERMIT NO. ROAD PERMIT NO. © O by the permit is for one hundred dollars ($100) oI less.) AFFIDAVIT WAIVER EASEMENT RECORD. INSTR, NO. DATE U CIT TEL. NO. / L] cc I certify that in the performance of the work for which this LEGAL O permit is issued, I shall not employ any person in any manner DESCRIPTION LOT N HWY. OR ST. WIDENING I— so as to become subject to the Workers' Compensation Laws. U BLOCK TRACT STATE ENCROACHMENT LL Date Applicant NO. OF BLDGS. PERMIT NO. U) NOTICE TO APPLICANT: If, after making this Certificate of SIZE OF LOT NOW ON LOT z Exemption, you should become subject to the Workers' USE OF CHARGES Compensation provisions of the Labor Code, you must forth- BUILDINGS With comply with such provisions or this permit shall be CONTRACTOR CONNECTION CHARGE FEE deemed revoked. REIMBURSEMENT FEE LICENSED CONTRACTORS DECLARATION ADDRESS DISTRICT NO. GROUP MAP PROC SSED BV I hereby affirm that I am licensed under provisions of Chapter CITY NO. ./ BK PG 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full force and STATE ^? L �D LICENSE NO. - CLASS effect. �J /�j /' NO. DESCRIPTION OF WORK S.E E^ r ^/` R / �//J � FINAL VALIDATION License Num �d HOUSE SEWER CONYT.,ic.Class `s�G �iJJJ PUBLIC SEWER DATE —� _ SEPTIC TANK,SEEPAGE rIT OR(::? Contra ClO PITS AND/OR DRAINFIELD FINAL .� HOUSE SEWER CONNECTING TO BY fr "ICmG F1 PRIVATE DISPOSAL SYSTEM 4' I am exempt from the licensing requirements as I am a CONNECT ADDITIONAL BLDG. OR licensed architect or a registered professional engineer WORK TO HOUSE SEWER acting In my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT, DRAINFIELD me$$and Professions Code). EXTN.,CESSPOOL,DR-ELL,MANHOLE ALTER,REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's OWNERS Permit s ° License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE ness and Professions Code): I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- ' TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING 1, as owner of the property, will do the work and the TO THE PUBLIC SEWER. structure is not intended or offered for sale (Section SIGNED THIS DAV OF Az 1 '6 5 8 A 19` 7044, Business and Professions Code). OWNER OR # D o 0,0 1 OWNERS AGENT 0 CONSTRUCTION LENDING AGENCY ADDRESS Z D ° 1 8 O O A hereby affirm that there is a construction lending agency for the performance of the work for which this permit is _ issued(Sec. 3097,Civ.C.). O D 0 1 8.0 0 cJ Lender's Name 0 8, 1 1 -80 Lender's Address I certify that I have read this application and state that the above information is correct. I agree to,comply with all County < inances and State laws regulating Plumbing and Sewers, n hereby authorize epre e atives of this Co my to enter ap eabove-ment' ed r pert for inspect' n purpos s.eSEE REVERSE FOR EXPLANATORY LANGUAGE I . G Ignatuf 6rmi t Dat,