HomeMy Public PortalAbout11006 GREEN TREE LN_Sewer__ WORKERS'COMPENSATION DECLARATION `)
1 hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or CE 808(
a certified o thereof (Sec. 38 Lab C.) CE 808(REV.B/81) APPLICATION FOR PERMIT
Policy No Company CA\�\�C) mno� i
wAtk
El 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.
DateApplicant `�C\. "MaM7)`:!1 . FOR APPLICANT TO FILL IN. CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION DEPTH
COMPENSATION INSURANCE ADDRESS .r(
MANHOLE REFERENCE UPPER
(This section need not be completed if the work involved by the
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.
permit is issued, I shall not employ any person in any manner P.C.NO.
so as to become subject to the Workers'Compensation Laws. OWNER CO.IMP.NO. JOB NO.
MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
Date In? , Applicant MC rrOnP� ADDRESS51? 1 _
NOTICE TO APPLICANT: If, after makingthis Certificate Of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
CITY �' TEL.NO.
Exemption, you should become subject to the Workers' LEGAL w
Compensation provisions of the Labor code, you must forth W ith DESCRIPTION LOT NO. 2— HWY.OR ST.WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT STATE ENCROACHMENT g
LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO.
SIZE OF LOT NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter USE OF
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 .. CONNECTION CHARGE FEE
License Number `t U,Lic.Class C ADDRESS 0 _" REIMBURSEMENT FEE
Contractor \ fax ` nt, Date�, ��� CITY TEL.NO. �""I� �., DISTRICT NO. GROUP BK MAP PROCESSED BY
PG
❑ 1 am exempt under Sec. of the L.A.Co. STATE LICENSE NO. CLASS \®/
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL
HOUSE SEWER CONNECTING TO DATE _ VALIDAT N
B. & P. Code for the following reason PUBLIC SEWER
SEPTIC TANK,SEEPAGE PIT OR FINAL
Date PITS AND/OR DRAINFIELD BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM
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 ;2 3 4 Q O A
❑ I,as owner of the property,or my employees with wages as
their sole compensation, will do the work and the structure # 0 0 0 0 1 (J
is not intended or offered for sale (Section 7044, Business Permit $ o o27,50
and Professions Code). OWNERS �.
❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE x
licensed contractors to construct the project (Section 7044, HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO o O o Z 7.5 0 U
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. 1 1.0 `�p 5
CONSTRUCTION LENDING AGENCY , J I J U
I hereby affirm that there is a construction lending agency SIGNEDTHIS�DAYOF 19
for the performance of the work for which this permit is OWNER OR
P p
issued (Sec. 3097, Civ. C.). OWNERS AGENT
ADDRESS
Lender's Name ` \
Lender's Address U ` YIJ� co—
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 the above-mentioned property for inspection purposes.
'm, M0,rrone, n - 22-
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE