HomeMy Public PortalAbout6243 GOLDEN WEST AVE_Sewer__ WORKERS' COMPENSATION DECLARATION 20-0051 DPW 6/89
1 hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, or 76A6a2D
01ceraifiedri Ry t ere Woo, �y9 APPLICATION FOR PERMIT
Policy N Y /�� SEWER - SEWAGE DISPOSAL
❑l Certified copy is hereby furnished.
LJ Certified copy'is filed with the county building inspection .COUNTY OF LOS ANGELES BUILDING AND.-SAFETY
department. //�y�j/�
Dare 0/93 Applican t!5 7/ � �e FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ADDRESS STATION DEPTH
DEPTH
(This section need not be completed if the work Involved by the MANHOLE REFERENCE PP
permit is for one hundred dollars ($100)or less.) LOCALITY Ile LOWER
NEAREST TYPE OF CONNE TION LENGTH FROM���
I certify that in the performance of the work for which this CROSS ST. v CU B' P L M L TO P L
permit is issued, 1 shall not employ any person in any manner LEGAL
SO a5 f0 become subject 10 the Workers' Compensation Laws. PC NO
DESCRIPTION LOT NO. CO IMP NO JOB NO
Date Applicant BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
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 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
PIC
I hereby affirm that I am licensed under provisions of Chapter OWNER
9 (commencing with Section 7000) of Division 3 of the Busi- MAIL ] VM
ness and Professions Code, and my license is in full force and ADDRESS , /f E, D CHARGES
P ) OCONNECTION CHARGE FEEeffect. `"� CIT N .
License NLer Lic. Class /6�—
REIMBURSEMENT FEE
jry / CONTRACTO !`
Contract r /o(• ��i�� r DISTRICT NO GROUP MAP PROCESSED BY
ADDRESS BK PG
❑ I am exempt under Sec. of the L.A.Co. ,{ / fT
CITYNII TEL.NO. �DV /�-- 17Q a
Plumbing Code and/or Sec. of the STATE f LIC. ��� FINAL o
LICENSE NO, F CLASS DATE VALIDATION
G t Z
B. 8 P. Code for the following reason NO. DESCRIPTION OF WORK FEE �"� C7 'G"C 0
HOUSE SEWER CONNECTING TO FINAL
Date PUBLIC SEWER BY
SEPTIC TANK SEEPAGE PIT OR L� /�.('Er a
Signature PITS AND OR DRAINFIELD 0-
HOUSE SEWER CONNECTING TO
OWNER-BUILDER DECLARATION PRIVATE DISPOSAL SYSTEM Z
I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR
Law for the following reason (Secton 7031.5, Buisness and Pro- WORK To HOUSE SEWER
fessions Code): OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN.CESSPOOL.DRYWELL,MANHOLE Vii:{;T.
❑ 1, as Owner Of the property, Or my employees with wages as ALTER.REPAIR OR ABANDON HOUSE —_
SEWER OR DISPOSAL SYSTEM fir` '
i{ _3n f2
their sole compensation, will do the work and the structure _ V
is not intended or offered for sale (Section 7044, Business 1-•�.
and Professions Code). I IT CML'
❑ I, as owner of the property, am exclusively contracting with ;3 i 1 HL 59- 30
licensed contractors to construct the project (Section 7044, OWNERS Permit $ '05gs
Business and Professions Code). AUTHORIZATION TOTAL FEE ,� `-'1141E :K'. --;4.�413
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON RACTOR To , CHANGE a Ti 1
I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER
for the performance of the work for which this permit is
issued (Sec. 3097, Civ. C.). SIGNED THIS DAY OF 19_
OWNER OR
Lender's Name OWNERS AGENT `y L '
Lender's Address ADDRESS SJ59 q 9 Exit 11
I y t of I hq read this app c ion and state that the
above informO on is correct. I ogre comply with all County
dinances and State laws regul ng Plumbing and Sewers,
and authorize representor es of this County to enter
he ab -mentioned proper y f r Ins ction purposes.
of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE