HomeMy Public PortalAbout11014 GREEN TREE LN_Sewer__ WORKERS'COMPENSATION DECLARATION (2-80)
CE 808 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- (Sec. 38 tab.C.). COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. ompany ` �O ) ` �..
D Certified copy is hereby furnished. FOR APPLICANT TO FILL IN 014NE6TION DATA
BUILDING STATION DEPTH
Certified count ADDRESS
copy is filed with the
p y building inspection
de artmen t. i^
LOC ALITYMANHOLE REFERENCE UPPER
LOWER
DateApplicantNEAREST 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.
MAIL CL
(This section need not be completed if the work Involved ADDRESS L , TRUNK PERMIT NO. ROAD PERMIT NO. (O
by the permit is for one hundred dollars ($100) or less.) AFFIDAVIT WAIVER EASEMENT RECORD. INSTR. NO. DATE U
CITY TEL. NO.
I certify that in the performance of the work for which this LEGAL O
permit is issued, I shall not employ any person in any manner DESCRIPTION LOT NO. HWY, OR Sl'. WIDENING 0
so as to become subject to the Workers' Compensation Laws. U
' BLOCK TRACT STATE ENCROACHM T UJ
PERMIT NO. a
Date Applicant NO. OF BLDGS. to
NOTICE TO APPLICANT: If, after making this Certificate of SIZE OF LOT NOW ON LOT �; 1 Z
USE OF e
Exemption, you should become subject to the Workers' CHARGES
Compensation provisions of the Labor Code, you must forth- BUILDINGS
with comply with such provisions or this permit shall be CONRACTOR~'° CONNECTION CHARGE FEE
T
deemed revoked.
LICENSED CONTRACTORS DECLARATION ADDRESSMM
^) ex REIMBURSEMENT FEE
I hereby affirm that I am licensed under provisions of Chapter s DISTRICT N`O,�. G oDP BK MAP PG PROCESSED BY t
9 (commencing with Section 7000) of Division 3 of the Busi- clry �� ^i , TEL. No. �� �,`!0�
ness and Professions Code, and my license is in full force and STATE LIC.
effect. LICENSE NO. CLASS
// NO. DESCRIPTION OF WORK FEE
�'�o-�QQ/� C(/ �� HOUSE SEWER CONNECTING TO FINAL VALIDATION`
License Numbet �1 Is 94, Lic. Class C PUBLIC SEWER /7. DATE
,./ SEPTIC TANK,SEEPAGE PIT OR
���,1 '^� R��y PITS AND/OR DRAIN F IELD
Contractor i Datey L /X ) FI
HOUSE SEWER CONNECTING TO
❑ 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 (�
I herebyaffirm that I am exempt from the Contractor's OWNER'S Permit f ' L.
8 8
License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION I TOTAL FEE '1 1.0 U
ness and Professions Code): , HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- I
❑ TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
I, as owner of the property, will do the work and the TO THE PUBLIC SEWER*
structure isnot intended or offered for sale (Section SIGNED THIS�_DAY OF
7044, Business and Professions Code). OWNER OR y —k
�)�y��{t
OWNERS AGENTr
Ill I \\ 1\ ,
CONSTRUCTION LENDING AGENCY ADDRESS
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is �; m®1 ca
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
`M.
Signature of Permittee Date