HomeMy Public PortalAbout10056 GREEN ST_Sewer__ rWORKERS'COMPENSATION DECLARATION
-by affirm that I have a certificate of consent to self
,sure, or a certificate of Workers'Compensation Insurance, or 92-0002 DP W5/87
a certified copy thereof(Sec. Lab C. 78A8APPLICATION FOR PERMIT
Policy No./05'65.33 Companyny,5)`Rfc DoT r�s/t7�Ja.� (CE 808)08)
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIVISION
department.
Date lJ Applicant SP ;?,o L E x— FOR FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' [A'U'
LDING STATION DEPTH
COMPENSATION INSURANCE DRESS D( e /f ��
(This section need not be completed if the work involved by the MANHOLE REFERENCE LIPPER
OWER
permit is for one hundred dollars ($100)or less.) CALITY 7�
I certify that in the performance Of the work for which this OSSNE
NEARESST. ��( TYPE OF CONNECTION LENGTH FROM
5/� �✓ � ✓G . Y. CURE P.L. M.L.TO P.L.
permit is issued, I shall not employ any person in any mannerso as to become subject to the Workers'Compensation Laws. P.C.NO.
WNER �C° N U CO.IMP.NO. JOB NO.
DateApplicantDRESMAIL S Q (�� Z£ /✓ S 'E.Fri TRUNK PERMIT NO. ROAD PER
NO.
NOTICE TO APPLICANT: If, after making Certificate othis f CITY /7E/ -* C. TEL_ i '�.NO00 AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
/1 .
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 Lor
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busi- USE BU Lo NGS ' % /✓C E CHARGES
ness and Professions Code, and my license is in full force and
effect. o CONTRACTOR (� 6 /`�-"' CONNECTION CHARGE FEE
License Number, LIC.Class ADDRESS REIMBURSEMENT FEE
Contractor ex—JS Date 1791 CITY` 4L / _ DISTRICT NO. GROUP MAP PROCESSED BY
TEL.NO. /p<,5 PG
QQ.
❑ I am exempt under Sec. _of the L.A.Co. LICENSE NO.� aa,Ss �_ g
VGJ �ZNO. DESCRIPTION OF WORK FEE —3
Plumbing Code and/or Sec. of the
HOUSE SEWER CONNECTING TO // % FDATE INAL
B. 8 P. Code for the following reason PUBLIC SEWER Ll VALIDATION
SEPTIC TANK,SEEPAGE PIT OR
Date PITS AND/OR DRAINFIELD FIN W
HOUSE SEWER CONNECTING TO A,
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR Z
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD
I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE
Law for the following reason (Secton 7031.5, BUisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM
❑ 1,as owner of the property,or my employees with wages as
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permit
$
❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEEM 77
licensed Contractors to construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONT ACTO]TO
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.CONSTRUCTION LENDING AGENCYI hereby affirm that there is a construction lending agency SIGNED THISDAY OF 19
for the performance of the work for which this permit is OWNER OR
OWNERS AGENT - -
issue (Sec. 3097, Civ. C.). ..
ADDRESS --- -
Lender's Name
Lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorize representatives Of this County to enter
upon thea e-mentioned property for inspection urPoses.
f
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE