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HomeMy Public PortalAbout11011 GREEN TREE LN_Sewer__ :YORKERS'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'Compensation Insurance,or 'fl a certifiedo y h reof(Sec. iso Lab. C. COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. CompanyNO- 1 Certified copy is hereby furnished. FOR APPLICANT TO FILL IN CONNECTION DATA ' BUILDING STATION DEPTH Certified co is filed with the county building ADDRESS copy g inspection `` � UPPER d aftmen // �� T� MANHOLE REFERENCE __E1, LOCALITY l-� LOWER 11 • Date Applicant- I r ry_1_ NEAREST TYPE OF CONNECTION LENGTH FROM CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. Y. CURB P.L. M.L. TO P.L. COMPENSATION INSURANCE P.C. NO. OWNER CO. IMP. NO. JOB NO. (This section need not be completed if the work involved ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO. 0 by the permit is for one hundred dollars ($100) or less.) O CITY TEL. NO. AVI f AFFIDT WAIVER EASEMENT RECORD, INSTR, NO. GATE I certify that in the performance of the work for which this LEGAL permit is issued, I shall not employ any person in any manner DESCRIPTION LOT NO. HWY. OR ST. WIDENING so as to become subject to the Workers' Compensation Laws. U ,('�,^�/�, �/'�/^/�,/� BLOCK TRACT STATE ENCROACHMENT tL CL Date Applicant \ S 9 1� \ \ \ 1\ e� PERMIT NO. to NO. OF BLDGS. Q''C CL NOTICE TO APPLICANT: If, after making this Certificate of slzE of Lor Now ory LOT �( S j�[ / LJ Z Exemption, you should become subject to the Workers' USE of Compensation provisions of the Labor Code, BUILDINGS CHARGES p p you must forth- CONNECTION CHARGE FEE with comply with such provisions or this permit shall be CONTRACTOR deemed revoked. LICENSED CONTRACTORS DECLARATIONADDRESS , A REIMBURSEMENT FEE �` I hereby affirm that I am licensed under provisions of Chapter 4 KDISTRICT N_O... GROUP MAP PR OBEs ED 6Y CITY ` TEL. NO. ^ _1♦,/ ABK PG 1/\//�//'/d/ I (commencing with Section need d Division 3 of the Busi- (//�(VJI jU1 ness and Professions Code, and my license is in full force and STATE LIC. 4 LICENSE NO. CLASS effect. C NO. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO FINAL VALIDATI N License Numbers - Llc. Class PUBLIC SEWER DATE 7%�y�\'y^q'�`- (�/^/'') Srj SEPTIC TANK,SEEPAGE PIT OR Contractor \ /1 I� Date ©` L/Ioi [J� PITS AND/OR DRAINFIELD FINIX HOUSE SEWER CONNECTING TO BY Q PRIVATE DISPOSAL SYSTEM I am exempt from the licensing requirements as I am a 142 CONNECT ADDITIONAL BLDG.OR licensed architect or a registered professional engineer WORK TO HOUSE SEWER acting In my professional capacity (Section 7051, BUS- OVERFLOW SEEPAGE PIT, DRAINFIELD Ines$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 I hereby affirm that I am exempt from the Contractor's OWN ER'SPermit E License Law for the fallowing reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE z 3 4 Q 9 A ness and Professions Code): I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING # O O O O 1 0 I, as owner of the property, will do tlie work and the TO THE PUBLIC SEWER. structure is not intended or offered for sale (Section SIGNED THIS­2_�' _DAY OF �� 19-a5 D - 27.50 7044, Business and Professions Code). OWNER OR OWNERS AGENT �rn �� nJ CONSTRUCTION LENDING AGENCY ADDREss cc {oCl �`.1y-c l l�L� ­ 27, 5006 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is S1 C^ 1 1, 05'-85 issued (Sec. 3097,Civ.C.). / (�l 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 gignature of Permittee Date