HomeMy Public PortalAbout11002 GREEN TREE LN_Sewer__ I
WORKERS'COMPENSATION DECLARATION CE 808 (D2-80) APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL
insure, or a certificate of Workers'C pensation Insurance,or
a certified y t r of Sec. 38o b.C COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Comp
an 1 ;
Certified copy is hereby furnished. FOR APPLICA T TO FILL IN CONNECTION DATA
BUILDING /, ,� vy� STATION DEPTH
Certified copy is filed witt, th�j cynty-�Luilding inspection AODREss G' �L �/ UPPER
department. y �� LOC ALIT �� MANHOLE REFERENCE LOWER
Date 6'%�'� Applicant /J NEAREST TYPE OF CONNECTION LENGTH FROM
CERTIFICATE OF EXEMPTION FROM WORKERS' cRoss ST. Y. CURB P.
M.L. TO P.L.
COMPENSATION INSURANCE P.C. NO.
OWNER CO. IMP. NO. JOB NO.
MAIL
(This section need not be completed if the Qwork inv8lved JiDDRES TRUNK PERMIT NO. ROAD PERMIT NO.
by the permit is for one hundred dollars (7100) or less.) AFFIDAVIT WAIVER EASEMENT RECORD. INSTR. NO. DATE IL
•1 CITY TEL. NO. Q — � O
I certify that in the performance of the work for which this LEGAL
permit is issued, I shall not employ any person in any manner DESCRIPTION LOT NO. HWY. OR ST. WIDENING 1c
so as to become subject to the Workers' Compensation Laws. O
BLOCK TRACT STATE ENCRO HMENT
PERMIT NO. V
Date Applicant NO. OF SLOGS. LLJ
NOTICE TO APPLICANT: If, after making this Certificate of SIZE OF LOT NOW ON LOT i 1 O_
Exemption, you should become subject to the Workers' USE of CHARGES
Compensation provisions of the Labor Code, you must forth- BUILDINGS
with comply with such provisions or this permit shall be CONTRACTO 5�04/4 �- � CONNECTION CHARGE FEE
deemed revoked.
/ REIMBURSEMENT FEE
LICENSED CONTRACTORS DECLARATION ADDREs (f/D 6e
I hereby affirm that I am licensed under provisions of Chapter DISTRICT NO. GR UP MAP PG PROCESSED BY
9 (commencing with Section 7000) of Division 3 of the Busi- STATE LIC.
CITY �fj ' TEL. No. � � BK�� �
ness and Professions Code, and my license is in full force and LICENSE NO. CLASS
effect. (� NO. DESCRIPTION CT WORK FEE
HOUSE SEWER CONNECTING TO FINAL VALIDAT N
License Numb Lie. Class PUBLIC SEWER 2`JO DATE
�j/J' /Q �� �� SEPTIC TANK,SEEPAGE PIT OR
Contracto
/!/e Date PITS AND/OR CONNECTING
FIN
HOUSE SEWER CONNECTING TO B
/ O PRIVATE DISPOSAL SYSTEM
I am exempt from the licensing requirements as I am a
CONNECT ADDITIONAL BLDG.OR
licensed architect or a registered professional engineer J WORK TO HOUSE SEWER
acting in my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT, DRAINFIELD
iness and Professions Code). EXTN.,CESSPOOL,DRY WELL, MANHOLE
ALTER, REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
Lic.or Reg.No. Date
'_SOME OWNER-BUILDER DECLARATION
I/l, by affirm that I am exempt from the Contractor's OWN ER$ Permit $ AjQ
Lic e Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE Q
nes nd Professions Code): 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
YRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING 2339.9A
I, as owner of the property, will do the work and the TO THE PUBLIC SEWSJ%} �/
� 7
structure is not intended or offered for sale (Section SIGNED THIS :T•� AY OF tri C
044, Business and Professions Code). OWNER OR -0 ,,02070H
0 ,,02070
OWNERS AG NT
CONSTRUCTION LENDING AGENCY ADDREss 2 7.5 0 5
I hereby affirm that there is a construction lending agency
.i.or the performance of the work for which this permit is ��i1
issued(Sec.3097,Civ.C.). f1 �, 1. 05"85
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 authoSize representatives of this County to enter
upon the abo ntioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
x_45
Signature of Permittee Date