HomeMy Public PortalAbout11003 GREEN TREE LN_Sewer__ WORKERS'COMPENSATION DECLARATION
I"hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or 76A642D
a certifieqq y thereof (Sec. 38 Lab C. CE BOB(REV.B/B)> APPLICATION FOR PERMIT
Policy NO. ComponyTeCU e) MR/�, S
❑ 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 In-27 Applicant Y\1 VfkaK 'CCS FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING I T STATION DEPTH
COMPENSATION INSURANCE ADDRESS
(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
NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that in the 'performance of the work for which this CROSS ST. Y. CURB P.L. M.L.TO P.L. Y
permit is issued, I shall not employ any person in any manner ®'
so as to become subject to the Workers'Compensation Laws. OWNER R �' CO.IMP,NO. JOB NO .
�s MAIL r TRUNK PERMIT NO. ROAD PERMIT NO.
Date ih - Applicant �� �_0-r V nl I_ ADDRESS 1,
AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
NOTICE TO APPLICANT: If, after making this Certificate of CITU TEL.No. �� '0
Exemption, you should become subject to the Workers' LEGAL IPS
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 NOOF BLDGS. PERMIT NO.SIZE OF LOT NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter USE OF 5
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 Ic
CONNECTION CHARGE FEE /
License Numbers - Lic.Class CA(" ADDRESS d _ REIMBURSEMENT FEE I
Contractor�Y 11 C_TQ nQ, Date 0� 7_a m l� 4'44DISTRICT NO. GROUP MAP P CESSED•BY
CITY TEL.NO. 1 BK PG
STATE LIC. r
❑ I am exempt under Sec. of the L.A.Co, LICENSE NO. CLASS
NO. DESCRIPTION OF WORK FEE
Plumbing Code and/or Sec. of the FINAL
HOUSE SEWER CONNECTING TO /r/ DATE �.. VALIDATION
B. & P. Code for the following reason PUBLIC SEWER
SEPTIC TANK,SEEPAGE PIT OR FINAL
PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO BY
.PRIVATE DISPOSAL SYSTEM /r
Signature CONNECT ADDITIONAL BLDG.OR
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 -
❑ I,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 4 1. 1 A
and Professions Code). OWNER'S Permit $ I
❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE 21 # 0 0 0 0 1 0
licensed contractors to construct the project (Section 7044, 1 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. o o2 7.50
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19 , o 0 0 2 7.5 Q c�
for the performance of the work for which this permit is OWNER OR O
OWNERS AGENT >
issued (Sec. 3097, Civ. C.). // pp --/ � ��'] 1 1.05-85
Lenders Name ADDRESS I�I� ")k 1�&V H14:� li W
Lender's Address Cil r.► vU� j C .
I certify.that 1 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 the above-mentioned property for inspection purposes.
YY� :
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE