HomeMy Public PortalAbout6245 GOLDEN WEST AVE_Sewer__ I WORKERS' COMPENSATION DECLARATION
20-0051 DPW 6189
1 -hereby affirm that I have a certificate of consent to self
Insure, or a certificate of Workers' Co pe sation Insurance, or 76A6a2D APPLICATION
p� wB C p PERMIT pip T
Pol(c�/fd opy� hereof (Se n800, a C /`1Pr LI�sAT'®ice I-®R r�R�Y�I1
❑ Certified copy is hereby furnished. ���% SEWER - SEWAGE DISPOSAL
Certified copy is filed with t county buil risp coon COUNTY OF LOS ANGELES BUILDING AND SAFETY
dep rtm
Date Applican jn FOR APPLICANT TO FILL IN CONNECTION DATA
ERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING "�
COMPENSATION INSURANCE ADDRESS - STATION �� DEPTH
(This section need not be completed if the work involved by the LOCALITY MANHOLE REFERENCE �!�3 LOWER
permit is for one hundred dollars ($100) or less.)
NEAREST TYPE OF CONN TION LENGTH FROM f
I certify that in the performance of the work for which this CROSS ST. v cuRB P L M L TOP L.
permit is issued, I shall not employ any person in any manner LEGAL PC NO
so as to become subject to the Workers' Compensation Laws. DESCRIPTION LOT NO. CO IMP NO JOB NO
BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
Date Applicant
NOTICE TO APPLICANT: If, otter 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
PERMIT NO
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter OWNER
9 (commencing with Section 7000) of Division 3 of the Busi- MAIL ' CHARGES
ness and Professions Code, and m,/license is in full foice and ADDRESS
effect. �•1� 1/ —�p Z )� CI T .N 22
CONNECTION CHARGE FEE
License m ergri G/V S(C3- Lic.CIOSS {/(�� -„/{"4�,�' REIMBURSEMENT FEE
CONTRACT 11
COntraC Or Date DISTRICT NO GROUP MAP PROCESSED BY
ADDRESS 1 BK PG
❑ I am exempt under Sec. of the L.A. Co. O
a� D }
CIT%,,y"-1 '
NO. �!� CJ a
Plumbing Code and/or Sec. of the STATE LIC. { FINAL U
LICENSE NO. CLASS DATE VALIDATION
B. 8 P. Code for the following reason NO. DESCRIPTION OF WORK FEE �"��— El O
HOUSE SEWER CONNECTING TO /i'{ INA
F-
Date / PUBLIC SEWER 7 5/ _ U
SEPTIC TANK SEEPAGE PIT OR -f” �• " I.• �- IL. UJIa
Signature PITS AND OR DRAINFIELD
g OWNER-BUILDER DECLARATION HOUSE SEWER SAL SYSTEM To FikA.i .-T Z
PRIVATE DISPOSAL SYSTEM —
I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR -7-70-7 �_' 7
Law for the following reason (Secton 7031.5, Buisness and Pro- WORK TO HOUSE SEWER �L o•_T_
OVERFLOW SEEPAGE PIT DRAINFIELD
fessiOnS Code): EXTN,CESSPOOL.DRYWELL.MANHOLE 1 ITEMS
❑ 1,as owner of the property, or my employees with wages as ALTER.REPAIR OR ABANDON HOUSE {TOTAL ��� :30their sole compensation, will do the work and the structure SEWER OR DISPOSAL SYSTEM
is not intended or offered for sole (Section 7044, Business CHECK r'CC•; -r �i i
and Professions Code). L_t. :=,_._
❑ I, as owner of the property, am exclusively contracting with OWNER'S Permit JCONIRA -CHANGE
HANGE �I I
licensed contractors to Construct the project (Section 7044,
Business and Professions Code). AUTHORIZATION TOTAL FEE _ _
CONSTRUCTION LENDING AGENCY HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAM ® II(I�—%111;' = ?jj''I
I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE ' � Ji Lfor the performance of the work for which this permit is �� �4issued (Sec. 3097, Civ. C.). SIGNED THIS DAY OF
OWNER OR
Lender's Name OWNERS AGENT '
Lender's A S ADDRESS
I c ' y that71h ve read thi pplication and state that theOve informn is correct. gree to comply with all County
rdinances and State laws gulating Plumbing and Sewers,
an eby authorize rep ento,—s of this County to enter
u e ove-mentioned roper r nspection urpa es.
t
i no of ermiit Date SEE REVERSE FOR EXPLANATORY LANGUAGE