HomeMy Public PortalAbout11021 GREEN TREE LN_Sewer__ WORKERS'COMPENSATION DECLARATION E 808 ((2-80)
CAPPLICATION FOR PERMIT
CE 80
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 certifie thereof(Sec. 38 Lab.C - COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company�V �� �� S�. 1
11 FOR APPLICANT TO FILL IN CONNECTION DATA
Certified copy is hereby furnished.
BUILDING ./-. il STATION DEPTH
E
Certified copy is filed with the county building inspection ADDRSS UPPER
department, MANHOLE REFERENCE
(� {� LOCALITY LOWER
Date Applicant��, `-,� �� 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
nIS section need not be completed if the work involved ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO. >_
the permit is for one hundred dollars ($100) or less.) AFFIDAVIT WAIVER EASEMENT RECORD. INSTR. NO. DATE C'
CITY r TEL. NO. f O
tify that in the performance of the work for,which thisLEGAL
is issued, I shall not employ any person in any manner DESCRIPTION LOT NO. HWY.,OR ST. WIDENING Ir
to become subject to the Workers' Compensation Laws. O
pp �f-C� BLOCK TRACT STATE ENCRO CHMENT
Applicant / NO. OF BLDGS. PERMIT NO. (�
SIZE OF LOT NOW ON LOT IL
TO APPLICANT: If, after making this Certificate of C 3 0.
:ion, you should become subject to the Workers' USE OF HARGES
nsation provisions of the Labor Code, you must forth- BUILDINGS Z
.omply with such provisions or this permit shall beCONTRACONNECTION CHARGE FEE
CTOR _
d revoked.
REIMBURSEMENT FEE
LICENSED CONTRACTORS DECLARATION qRt��� _ (�l-.,U
eby affirm that I am licensed under provisions of Chapter ADDRESS _ DISTRICT(N O. GROUP MAP PR OC SSeD B,�
ommencing with Section 7000) of Division 3 of the BuSi- CITY TEL. NO. �/ BK PG
and Professions Code, and my license is in full force and STATE Llc. ld 3
LICENSE NO. CLASS
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO FINAL VALIDAT N
nse Number Lia Class PUBLIC SEWER DATE � --�
`^ &57
� SEPTIC TANK,SEEPAGE PIT OR
V\A!'1 ./l�1 �/-�� lOO.m �J'�I'r PITS AN. DRAINFIELD
tractor\��\�tlCC9===\,,,�\11_{`� � Date y L( FINA
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 %OSI. Bus- OVERFLOW SEEPAGE PIT, DRAINFIELD
mess and Professions Code) EXTN.,CESSPOOL,ORYWELL,MANHOLE �y
ALTER, REPAIR OR ABANDON HOUSE 3 4 0. ! A
SEWER OR DISPOSAL SYSTEM 7
Lie.or Reg.No. Date
0 0 0 0 1 0
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's
OWNER'S Permit s I D - 2750
License Law for the following reason (Section 7031.5, Busi- AUTHORIZATIONTOTAL FEE D o 0 2 7.5 0 c=i
ness and Professions Code): I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
O - TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING �i I, 0 5
I, as owner of the property, will do the work and the TO THE PUBLIjC SEWER.
structure is not intended or offered for sale (Section SIGNED THIS-2-2 DAY OF C��&, 19
7044, Business and Professions Code). OWNER ORC`ncti'(-f0Y1�,
OWNERS AGENT n
CONSTRUCTION LENDING AGENCY ADDRESS G\ (Oc)_�h)eg— COY
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.). \
lorft
Lender's Name J
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