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HomeMy Public PortalAbout5813 GOLDEN WEST AVE_Sewer__ COMPENSATION DECLARATION have a certificate of consent to self insur.' ,(e of Workers'Compensation Insurance, or 76A6420 JLL1�� a (Sec. 3800, Lab C.) CE808(REV.8/81) ® PLI ATIOIV FOR PERMIT Policy No. Company ©s �-! ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION DEPTH COMPENSATION INSURANCE ADDRESS ' (This section need not be completed if the work involved by theLOCALIT C' MANHOLE REFERENCE UPPER LOWER permit is for one hundred dollars ($100)or less.) NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of,the work for which this CROSS ST. Y. CURB P.I. M.L.TO P.L. permit is issued, I shall not employ any person in any manner so as�;me sub'ect to the WorkW'Compensation LOWS. P.C. NO. I P OWNER� CO.IMP.NO. JOB NO. r' MAIL TRUNK PERMIT NO, ROAD PERMIT NO. Date Applicant® , ADDRESS 1 AFFIDAVIT WAIVER EASEMENT RECORD.INSTR._NO._ DATE • NOTICE TO APPLICANT: If, after makin-gJthiJ Certificate of CITY TEL. Exemption, you should become subject to the Workers' LEGAL 1. Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR,ST.WIDENING T comply with such provisions or this permit shall be deemed - --- revoked. BLOCK TRACT STATE ENCROACHMENT J 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. CONTRACTOR CONNECTION CHARGE,FEE' F " License Nu ber �� LIC.ClO ADDRESS ^ REIMBURSEMENT FEE- License a - DISTRICT NO. GROUP MAP P OCESSED BY 'CIT TEL.N % � BK PG ❑ I am exempt under4e f the L.A.Co. ^ 11 c. LICENSSTATE-E P LICENE NO. 1 CLASS NO. DESCRIPTION OF WORK FEE Plumbing Code and/or Sec. of the FINAL ;VLIpA QN HOUSE SEWER CONNECTING TO DATE � PUBLIC SEWER _ B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR fl L `J I 1 PITS AND/OR DRAINFIELD Date _ - HOUSE SEWER CONNECTING TO Y a PRIVATE DISPOSAL SYSTEM d. Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER _ ; = a a �r— E0 OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE — �(! Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE ` ' 'f"a"a SEWER OR DISPOSAL SYSTEM ,I. j:•r fessions Code): ;] ui u ❑ I,as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S Permit $ '� ii Fh'-_Eta: ❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE O 'r` L i s _=t5 licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO 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_ for the performance of the work for which this permit is OWNER pop issued (Sec. 3097, Civ. C.). OWNERS AGENT ADDRESS Lender's Name Lender's Address • 4' 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 a o e-mentio d property for insp tion purposes. Signal a of Permitte Da SEE REVERSE FOR EXPLANATORY LANGUAGE