HomeMy Public PortalAbout6032 GOLDEN WEST AVE_Sewer__ WORKERS'COMPENSATION DECLARATION `
I hereby affirm that I have a certificate of consent to self
irisure, or a certificate of Workers'Compensation Insurance, or 76A6420
a certifiedcopy thereof(Sec. 3800, Lob C.) 92-0002 DPW 6/88 APPLICATION FOR PERMIT
P61icy 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 IApplicant 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 the MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY LOWER
NEAREI certify that in the performance of the work for which this CROSS SST. TYPE OF CONNECTION LENGTH FROM
Y. CURB P.I. M.I.TO P.I.
permit is issued, I shall not employ any person in any manner P.C.No.
so as to become subject to the Workers'Compensation.La 5. OWNER CO.IMP.NO. JOB NO.
4 �y MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
Date�"— ::!g:/ Applicant� i�i�Z ADDRESS
NOTICE TO APPLICANT: If, after making CITY TEL.NO.
this Certificate of AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE
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 BUST- BUILDINGS CHARGES
ness and Professions Code, and my license is in full force and
effect. (A•,•�w' CONTRALTO CONNECTION CHARGE FEE
License Number Lic.Class �/�+4 ADDRESS REIMBURSEMENT FEE
Contractor Date '/ '] DISTRICT NO. GROUP MAP PROCESSED BY 0
CITY. TEL.N 44�3� /
p B PG
❑ lam exempt un Sec. of the L.A.Co. a ATI-- No. CLASS 3
Plumbing Co a d/or Sec. NO. DESCRIPTION OF WORK FEE of the FINAL VALIDATION In
HOUSE SEWER CONNECTING TO DATE
B. 8 P. Co f r the following reason PUBLIC SEWER QLI �� Z
SEPTIC TANK,SEEPAGE PIT OR FINAL
PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signatur CONNECT ADDITIONAL BLDG.OR
OWN - L -IIKJRKTION WORK TO HOUSE SEWER
I hereby affirm that I am exempt from the Contractor's License EOTN.,CESSPOOL,
SS SPOOL,DRYEPAGE WELR,4lNFIELD MANHOLE
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,
Ri ROR ABANDON
fessions Code): Ew REPAIR
DISPOSAL ii
❑ I,as owner of the property,or my employees with wages as P. C i,s
their sole compensation, will do the work and the structure
-,, 5.,
is not intended or offered for sale (Section 7044, Business .`:.`_�)! �4a_I_t
and Professions Code). OWNER'S Permit $ 1300
❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE L '''-`''`'
licensed contractors to construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO �1i6i
Business and Professions Cade). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. 1 r AL 34 c T
CONSTRUCTION LENDING AGENCY � i.•i'1s,.!•1': 64 :-IJ
'
I herebyaffirm that there is a construction lending agency SIGNED THIS D O O 1�
9 9 Y r• ALIO
is OWNER OR ® i;
for the performance of the work for which this permitrs i
issued (Sec. 3097, Civ. C.). OWNERS AGENT
ADDRESS
Lender's Name
Lender' ddress
6 cer y hat I have read this application and state that the ;?;?'T Fd a=•M a
ob e i formation is correct. I agree to comply with all County
or ina,no/
and State laws regulating Plumbing and-Sewers,
a d ereby outhorizrepresent Ives of this County to enter
o the abo - entia ed pro rty for inspection purposes.
Sign o mlttE; Date SEE REVERSE FOR EXPLANATORY LANGUAGE