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HomeMy Public PortalAbout6030 GOLDEN WEST AVE_Sewer__ WORKERS' COMPENSATION DECLARATION z DPW 3/e� I -hereby 9z-000 gffirm that I have a certificate of consent to self 92-00076A64D -insure, ora certificate of Workers'Compensation Insurance, or CE 808 �p a certified copy thereof (Sec. 3800, Lab C.) APPLICATION R PERMIT Policy No. Company ©s /� e! do®9—a ❑ 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 b the UPPER ( p �' LOCALITY MANHOLE REFERENCE LOWER permit is for one hundred dollars ($100)Or less.) LENGTH FROM NEAREST TYPE OF CONNECTION I certify that in the performance of the work for which this CROSS ST. Y. CURB P.L. M.L.TO P.I. permit is isiued, I shall not employ any person in any manter so as to become subject to the Workers'Com ensation La P.C.No. I p ' OWNER lz u � CO.IMP.NO. JOB NO, I MAIL Dat" Applicant ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO. � ` : If, after making s Certificate OAFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTICE TO APPLICANT' g thiCtifif :! CITY TEL.NO. Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed revoked. BLOCK TRACT STATE ENCROACHMENT 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 g RGE FEE License Numb e Lic.Class ADDRESS �aa11""� E O Contractor Date�� S OG GROUP MAP PROCESSED BY (� CITY TEL.N /Q y BK PG ❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. � clTATE ass Plumbing Cod a d/or Sec. ofthe No. DESCRIPTION OF ORK FEE WHOBLC SEWERCONNECTING TO VALIDATION a B. & P. Cod Xfr the following reason SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD FINAL Dat HOUSE SEWER CONNECTING TO BY OX PRIVATE DISPOSAL SYSTEM - Signatur CONNECT ADDITIONAL BLDG.OR W CL ATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE pooltt Law for the following reason (Secton 7031.5, BuiSnesS and Pro- ALTER,REPAIR OR ABANDON HOUSE E'_1 fessions Code): SEWER OR DISPOSAL SYSTEM ❑ I,as owner of the property, or my employees with wages as s "°- their sole compensation, will do the work and the structure } -.e is not intended or offered for sale (Section 7044, Business �. and Professions Code). OWNER'S Permit $ 30-0 AUTHORIZATION TOTAL FEE 1E3�% ❑ I,as owner of the property, am exclusively contracting with �`"j� .__, ..,,,,,� �, licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONT ACTOR TO i=t 1t— 13 ^. 43 Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. 4� _ _ �» CONSTRUCTION LENDING AGENCY 4' 4 't` '�a 5 i I hereby affirm that there is a construction lending agency SIGNED THIS DAY 19 � ® . » for the performance of the work for which this permit is OWNER A issued (Sec. 3097, CIV. C.). OWNERS GEN ADDRESS / Lender' me _.J J Le er's A dress I certify t at I have read this application and state that the bove in ormation is correct. I agree t comply with all County ordin es and Statregulati Plumbing and Sewers, and eby auth i e rep sentati s of-,this County to enter u o e ov ti proper in pection purposes. Ign P e Date SEE REVERSE FOR EXPLANATORY LANGUAGE