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Home My Public Portal About11015 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 ereof(Sec. 38 Lab. ) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy NoCCompany ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN 'CONNECTION DATA BUILDING STATION DEPTH Certified copy is filed with the county building inspection ADDRESS JJC)I y UPPER de artment. MANHOLE REFERENCE M Ma /�^p LOCALITY LOWER Date Applicant M \ l 1( -ICE 7� _e- 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. MAIL (This section need not be completed if the work involved ADDRESS F, TRUNK PERMIT NO. ROAD PERMIT NO. } by the permit is for one hundred dollars ($100) or less.) AFFIDAVIT I WAIVER EASEMENT RECORD. INSTR. NO. DATE a CITY TEL. NO. 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. Q �('�� y`�/''/'��/� BLOCK TRACT STATE ENC OACHMENT Date 10— -7- Applicant-\_l 1. \ 0 0_' \ n\ VcNO. OF BLDGS. PERMIT NO (� SIZEUSE OF LOT NOW ON LOT / C� UJ NOTICE TO APPLICANT: If, after making this Certificate of t / J C- Exemption, you should become subject to the Workers' BUILDINGS CHARGES Z Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be CONTRACTOR CONNECTION CHARGE FEE deemed revoked. REIMBURSEMENT FEE LICENSED CONTRACTORS DECLARATION ADDRESS a - I hereby affirm that I am licensed under provisions of Chapter DISTRICT NO. GROUP MAP P O ES 'ED BY CITY TEL. NO. •.� [/ � BK PG 9 (commencing with Section 7000) of Division 3 of the Busi- (//YI ness and Professions Code, and my license is in full force and STATE LIC. LICENSE No. �t effect. NO. DESCRIPTION OF WORK FEE tyC 3 FINAL VALID ION License Number< Lic.Class ( PUBLIC SEWER HOUSE SEWER CONNECTING TO DATEIZ C� C ((��11�� (/�^/ []�[, SEPTIC TANK,SEEPAGE PIT OR V v Contractor _�� i Date IV_ L L_ R5, PITS AND/OR DRAINFIELD FIN .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). ALTN.,CESSPOOL, DRY MANHOLE ALTER, REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM Lic.or Reg.No. Date 2340.8A , 1 HOME OWNER-BUILDER DECLARATION # D o D o 1 0 I hereby affirm that I am exempt from the Contractor's OWNERS Permit E a License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE D D 2 '5 ness and Professions Code): I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- O O o /�L 1 7] F U ,V 0 TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING EJ 1, as owner of the property, will do tlie work and the TO THE PUBLIC SEWER. r , structure is not intended or offered for sale (Section SIGNED THIS�_DAY OF C \ 19 �' 5 '$5 7044, Business and Professions Code), OWNER OR OWNERS AGENT CONSTRUCTION LENDING AGENCY pDDR E SS CQ\1l I hereby affirm that there is a construction lending agency for the performance of the.work for which this permit is TQC l issued(Sec. 3097,Civ.C.). Co- 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 Signature of Permittee Date