HomeMy Public PortalAbout5818 GOLDEN WEST AVE_Sewer__ WORKERS' COMPENSATION DECLARATION
1)
I hereby affirm that ,l have-a'certificate of consent to self 200051 DPW 6/89
nsurj�, or a CpFfificole-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. 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
COMPENSATION INSURANCE ADDRESS 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 CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. - v CURB P L M L To P L
permit is issued, I shall not employ any person in any manner LEGAL
PC NO
50 OS t0 become subject to the Workers' Compensation LOWS, DESCRIPTION LOT NO. CO IMP NO JOB NO
BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
Date Applicant
NOTICE TO APPLICANT: If, after makingthis Certificate Of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
MAP BOOK PAGE PARCEL
Exemption, you should become subject to the Workers' �••� NO.OF BLDGS.
Compensation provisions of the Labor code, you must forthwith SIZE OF LOT V 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 PERMIT NO
I hereby affirm that I am licensed under provisions of Chapter OWNER
Cdf A16- 4)44
9 (commencing with Section 7000) of Division 3 of the Busi- MAIL
ADDRESS CHARGES
ness and Professions Code, and my license is in full force and
effect. CITY TEL.NO. y � CONNECTION CHARGE FEE
License Number Lic. Class REIMBURSEMENT FEE
CONTRACTOR
Contractor Date DISTRICT NO GROUP MAP PROCESSED BY
ADDRESS y BK PG
❑ I am exempt under Sec. of the L.A.Co. j—d0 d
CITY TEL.NO. V,�J o
Plumbing Code and/or Sec. of the STATE LIC. FINAL U
LICENSE NO. CLASS DATE VALIDATION ZO
B. 8 P. Code for the following reason NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO FINAL F— '
Date PUBLIC SEWER BY d
SEPTIC TANK SEEPAGE PIT OR LU
Signature PITS AND OR DRAINFIELD 0-
OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING TO 1Q
PRIVATE DISPOSAL SYSTEM
I hereby affirm that I Om exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR �7 `� ACCT.JL
Law for the following reason (Secton 7031.5, Buisness and Pro- WORK TO HOUSE SEWER CIS
OVERFLOW SEEPAGE PIT.DRAINFIELD "r"'r
fessions Code): .t
) EXTN CESSPOOL.DRV WELL. MANHOLE alta � a
g1j, as owner of the property, or my employees with wages as ALTER REPAIR OR ABANDON HOUSE ITEMS
sole compensation, will do the work and the structure SEWER OR DISPOSAL SYSTEM
is not intended or offered for sale (Section 7044, Business TOTAL 57 - 20
and Professions Code). CHECK ��,71�1
❑ I, as owner of the property, am exclusively contracting with OWNER'S Permit $ �j
licensed contractors to construct the project (Section 7044, CHANGE .00
Business and Professions Code). AUTHORIZATION I TOTAL FEE O
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO ,
00
I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER ryQ� `QQQ J! �, J
for the performance of the work for which this permit is /
issued (Sec. 3097, Civ. C.). SIGNED THIS DAY OF 195 57,� i At,! Oa C7
OWNER OR 1VV 1 A 1 7
Lender's Name OWNERS AGENT
Lender's Address ADDRESS
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 above-mentioned property for inspection purposes.
�ign.ture of PdZMV1Date SEE REVERSE FOR EXPLANATORY LANGUAGE