HomeMy Public PortalAbout6036 GOLDEN WEST AVE_Sewer__ WORKERS'COMPENSATION DECLARATION .
I hereby'affirm that I have a certificate of consent to self
jr1sure;ora certificate of Workers'Compensation Insurance, or 76A642D
a certified copy thereof (Sec. 3800, Lab C.) 92-0002 DPW 6/88 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
I certify that in the performance Of the work for which this NEAREST TYPE OF CONNECTION
CROSS ST. LENGTH FROM
Y
permit is issued, I shall not employ any person in any manner cuRe P.L. M.L.TO P.L.
so as to become subject to the Workers'Compensation LOWS. P.C.NO.
OWNER CO.IMP.NO. JOB NO.
_ MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
Da ter/�4Appl i co n t, _ ADDRESS
NOTICE. TO APPLICANT: If, after making this Certificate of CITY TEL.NO. AFFIDAVIT I WJ EASEMENT RECORD.IN!77 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 DECLARATIONNO.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 CL
License Number �W Lic.Class (�f�
` ADDRESS REIMBURSEMENT FEE
Contractor Date if
gJ,/� DISTRICT NO. GROUP MAP PROCESSED BY z
CITY EL.Nl&?�iO331BK PG 0
❑ 1 am exempt under Sec. of the L.A.Co. LI ENSE NO. CLI LASS
O� -3 ,� 37
NO. DESCRIPTION OF WORK FEE
85
Plumbing 0ef
d/or Sec. of the FINAL VALIDATION f�
HOUSE SEWER CONNECTING TO ,C-y� DATE
B. & P. Cohe following reason PUBLIC SEWER d v 4. 5 �Gl z:
SEPTIC TANK,SEEPAGE PIT OR FINAL
PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTE
Slgn OtU CONNECT ADDITIONAL BLDG.OR
N A A IO - WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD
I hereby affirm that I exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE
Law for the following reason (Secton 7031.5, Buisnes5 and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM
t [ f1_ ;
❑ I,as owner of the property,or my employees with wages as
their sole compensation, will do the work and the structure 'TA I AL m 50
is not intended or offered for sole (Section 7044, Business &
and Professions Code). OWNER'S Permit $
❑ I, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE
licensed contractors to construct the project Section 7044, �U 'CHR.NIt5'E =I
P I ( I 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 D F 19V j j( €iE S—;jl¢ j 4,
for the performance of the work for which this permit is
issued (Sec. 3097, Civ. C.). OWNERS AGENT
NER OWOR
_
ADDRESS
t# 3 FI.. 8-,3,_�
Lender's Name
Lend s A dress
I c ify t t I have read this application and state that the
ab ve inf rmation is correct. I agree to comply with all County
o inanc s and State laws regulating Plumbing and Sewers,
d he by authorize representatives of this County to enter
pan a above-hTe Ion grope ty for inspection purposes.
ignatur r e Date SEE REVERSE FOR EXPLANATORY LANGUAGE