HomeMy Public PortalAbout11007 GREEN TREE LN_Sewer__ WORKERS'COMPENSATION DECLARATION D
CE 808 (2-80) APPLICATION FOR PERMIT
CE 808
I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL
insure, or a certificate of Workers'Compensation Insurance,or
a certified thereof(Sec. 38;9ik,�Lab. C) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No� Company
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN CONNECTION DATA
BUILDING �� STATION DEPTH
Certified copy is filed with the count building ADDRESS
p y g inspection UPPER
Otl
dart�jje�t. NEAREST TYPE OF CONNECTION LENGTH FROM
LOCALITY MANHOLE REFERENCE
Date _!-/ - Applicant • + `�e`�• LOWER
v
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. Y. CURB P.L. M.L. TO P.L.
COMPENSATION INSURANCE P.C. NO.
OWNER CO. I.P. NO. JOB NO.
MAIL
(This section need not be completed if the work involved ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO. �.
by the permit is for one hundred dollars ($100) Or less.) �•-y, AFFIDAVIT I WAIVER EASEMENT RECORD. INSTR, NO. DATE
CITY TEL. NO. l 1 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 tr
so as to become subject to the Workers' Compensation Laws. O
y--/' BLOCK TRACT STATE ENCROACHMENT
Date Applicant {�/�c, SIZE OF LOT NOW ON LOT PERMIT NO. U
NO. OF BLD GS.
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' USE OF t/7
CHARGES
Compensation provisions of the Labor Code, you must forth-
BUILDINGS
with comply with such provisions or this permit Shall beCONTRACTOR CONNECTION CHARGE FEE
deemed revoked.
LICENSED CONTRACTORS DECLARATIONREIMBURSEMENT FEE
ADDRESS
I hereby affirm that I am licensed under provisions of Chapter DISTRICT NO. GRROUP BK MAP PG P CESSED BY
CITY TEL. NO.9 (commencing with Section 7000) of Division 3 of the Busi- '^
ness and Professions Code, and my license is in full force and STATE LIC. `
(41
effect. LICENSE NO. CLASS 5
C NO. DESCRIPTION OF WORK FEE
/; �(�, HOUSE SEWER CONNECTING TO FINAL ,e� VALID ION
License Numben� `-1-- Lic.Class_ /—YO O PUBLIC SEWER DATE —�/
1 ^/ (X} SEPTIC TANK,SEEPAGE PIT OR
)1 �rh� YO
v
Contractor K
. Date ^ 1✓ — fl� PITS ANO/OR DRA INFI ELO
FINA
HOUSE SEWER CONNECTING TO BY /•
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 WORK TO HOUSE SEWER
{ acting In my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT,DRAINFIELD
iness and Professions Code). EXTN.,CESSPOOL, DRYWELL, MANHOLE
ALTER, REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION
OWNER'S Permit
I hereby affirm that I am exempt from the Contractor's
s :934 11 p A
License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE # o 0 0 0 0
ness and Professions Code): I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
❑ TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING •I ° - 2
7'5 0
I, as owner of the property, will do the work and the TO THE PUBLIC SEWER. L� I
structure is not intended or offered for sale (Section SIGNED THIS�DAY OF 19
7044, Business and Professions Code). ° °•° 2 7.5 0 cJ
=
OWNER OR *^_
,OWNERS AGENQT ^rF-Y1` ` t
CONSTRUCTION LENDING AGENCY ADDREss �Ll1. 05 =8 5
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued (Sec. 3097,Civ.C.).
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 the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Si ature of Permittee � Date