HomeMy Public PortalAbout11010 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^o!y'�thereof(Sec. 3800.�Lab. ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No� Compa., `1�t mcd
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN CONNECTION DATA
BUILDING STATION DEPTH
Certified co is filed with the count building ADDRESS T�
copy y g inspection UPPER
de art. a n MANHOLE REFERENCE
�� �')7 I� � - o LOCALITY LOWER
Date IY(e�_/y/� Applicant y �`i�� NEAREST TYPE OF CONNECTION LENGTH FROM
CERTIFICATE OF EXEMPTION FROM WORKERS' cRoss ST. Y. CURB P.L. M.L. TO P.L.
COMPENSATION INSURANCE r P.C. NO.
OWNER `� CO. IMP. NO. t" JOB NO.
MAIL
(This section need not be completed if the work involved ADDRESS ) j TRUNK PERMIT NO. ROAD PERMIT NO. }
by the permit is for one hundred.dollars ($100) or less.) a
�( AFFIDAVIT WAIVER EASEMENT RECORD. INSTR. NO. DATE
CITY ,. TEL. NO. t j
I certify that in the performance of the work for which this LEGAL
permit is issued, I shall not employ any person in any manner DESCRIPTION LOT NO. HWY. OR ST. WIDENING
o as to become subject to the Workers' Compensation Laws. Q
BLOCK TRACT STATE ENCROACHMENT
ate Applicant 1 I , rM)DE-1L NO. OF BLDGS. PERMIT NO. (�
SIZE OF LOT NOW ON LOT is
OTICE TO APPLICANT: If, after making this Certificate of 5 19IJ e-
Exemption, you should become subject to the Workers' USE O NGS CHARGES
Compensation provisions of the Labor Code, you must forth-
With comply with such�provlsions or this permit shall be 'CONTRACTORCONNECTION CHARGE FEE
._
eemed revoked. r REIMBURSEMENT FEE
LICENSED CONTRACTORS DECLARATION ADDRESS -
hereby affirm that I am licensed under provisions of Chapter DISTRICT No, GROUP BK MAP PG PROCESSED BY
(commencing with Section 7000) of Division 3 Of the BUST- EA 2mn�e_CITY TEL. NO. (/
ess and Professions Code, and my license is in full force and STATEC.
LICENSE No. L wss �p
ffect. NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO FINAL VALIDATION
License Number Lic.Class PUBLIC SEWER LcoDATE �J
SEPTIC TANK,SEEPAGE PIT OR
�`�(lcrr�h� j�j\ PITS AND/OR DRAINFIELD FIN
Contractor 1 l Datey L l>_J
HOUSE SEWER CONNECTING TO B
' PRIVATE DISPOSAL SYSTEM --'-
I am exempt from the licensing requirements as I am a CONNECT ADDITIONAL BLDG. OR
licensed architect or a registered professional engineer WORK TO HOUSE SEWER
acting in my professional capacity (Section 7051, BUS" OVERFLOW SEEPAGE PIT, DRAINFIELD
IRess and PiOfe$SIORS Code). EXT..,CESSPOOL,DRYWELL, MANHOLE
ALTER, REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
.ic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION -5340, 1 A
hereby affirm that I am exempt from the Contractor's OWN ER$ Permit f # O O o O 1 Q
icense Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE Z
less and Professions Code): I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- -.o27, 50
l'RACTOR TO CONNECT THE ABOVE DESCRIBED XISTING OW ELLING
I, as owner of the property, will do the work and the TO THE PUBLIC SEWER.
structure is not intended or offered for sale (Section SIGNED THIS AY of 19 O O ° 2 7.5 o v
7044, Business and Professions Code). OWER OR , f rd ne
OWNERS AGENT _m J 1.05 ` 85
CONSTRUCTION LENDING AGENCY gDDRESS
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 certifv 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
Signature of Permittee Date