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Home My Public Portal About11020 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 certifiedo �y('tt e7o�f(Sec. 38o Lab. C) p COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No ►'-)nCompany 1h FOR APPLICANT TO FILL IN '' CONNECTION DATA Certified copy is hereby furnished. BUILDINGLa STATION DEPTH Certified copy is filed with the county building inspection ADDRESS UPPER Datede art LOCALITY 1• MANHOLE REFERENCE LOWER Applicant 'L`C� �(��l 11Yl>° 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 � u S CO. IMP. NO. JOB NO. MAIL (This section need not be completed if the work involved ADDRESS I 1 TRUNK PERMIT NO. ROAD PERMIT NO. '_ by the permit is for one hundred dollars ($IOU) or less.) AFFIDAVIT I WAIVER EASEMENT RECORD, INSTR, NO. DATE 13- CITY CITY TEL. NO. f O I certify that in the performance of the work for which this LEGAL permit is issued, I shall not employ any person in any manner DESCRIPTION LOT NO. HWY. OR ST. WIDENING so as to become subject to the Workers' Compensation Laws. O �y�/��'-r1`� BLOCK TRACT STATE ENCRO CHMENT Date i � Applicant �. \I113"\ ` 11 NO. OF BLDGS. PERMIT NO. w NOTICE TO APPLICANT: If, after making this Certificate of SIZE OF Lor NOW ory Lor iL Exemption, you should become subject to the Workers' USE CHARGES � Compensation provisions of the Labor Code, you must forth- with comply with Such provisions or this permit shall be CONNECTION CHARGE FEE 'CONTRACTOR r deemed revoked. (n� REIMBURSEMENT FEE LICENSED CONTRACTORS DECLARATION ADDRESS `1 I L DISTRICT NO. GROUP MAP PROCESSED BY I hereby affirm that I am licensed under provisions of ChapterCA rnZ�Cft BK PG 9 (commencing with Section 7000) of Division 3 of the Busi- STATECITY TEL. No. \ ness and Professions Code, and my license is in full force and LICEN CLASS S LICENSE NO. CLASS effect, NO. DESCRIPTION OF WORK FEE C_ti FINAL- HOUSE SEWER CONNECTING TO ON y7 VALIDA llicense Number� �� Lie.Class PUBLIC SEWER DATE �'/I SEPTIC TANK,SEEPAGE PIT OR / Contractor Date 7L PITS AND DRAINFIELD HOUSE SEWER CONNECTING TO BY BY PRIVATE DISPOSAL SYSTEM 0 I am exempt from the licensing requirements as I am a CONNECT ADDITIONAL L.G.BOR licensed architect or a registered professional engineer WORK TO HOUSE SEWER acting in my professii�onal capacity (Section /051, BUS- OVERFLOW SEEPAGE PIT,OR AINFIELD Ines$and Professions Code). EXTN.,CESSPOOL, DRVWELL,MANHOLE ALTER, REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM Lie.or Reg.No. Date ;2340,3A HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's OWNER'S Permit s (,1< � # ° ° ° ° License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION I TOTAL FEE 7 1 D - 2750 ness and Professions Code): I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- OYRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING O O O 2 7. 0 U I, as owner of the property, will do ttie work and the TO THE PUBLIC SEW,)R structureis not intended or offered for sale (Section SIGNED THIS DAY OF .{ 1 is lI 0 5- 5 7044, Business and Professions Code). OWNER OR OWNERS AGENT CONSTRUCTION LENDING AGENCY ADDRESS a&l nD C -� Ko_, - i I hereby affirm that there is a construction lending agency o l l for the performance of the work for which this permit is , �� ` issued (Sec. 3097,Civ.C.). C 1 CL 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 h, moxyc)rx . l0" Signature of Permittee Date