HomeMy Public PortalAbout11024 GREEN TREE LN_Sewer__ WORKERS'COMPENSATION DECLARATION CE 808 (D2-80) APPLICATION FOR PERMIT I
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 cert fiecl,.Cogv the (Secp 38,O ,tLab.". COUNTY OF LOS ANGELES BUILDING AND SAFETY
Volic No. om any \�l_J.�� q �1n� '
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN tiC0NJVE&ION DATA
BUILDING / � STATION DEPTH
lee
Certified co is filed with the county building ADDRESS [) V`
copy g inspection UPPER
de' t_mP 't {1y/ �/�/� / /�y�/a 1 1 MANHOLE REFERENCE
__^�✓GGL.� `ILL . 1 r\ax �\ o LOCALITY LOWER
Date Applicant �iJ G 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.
CL
(This section need not be completed if the work involved MAIL 0
Q� ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO. 0
by the permit is for one hundred dollars ('U100) Or less.) } _ �� / I AFFIDAVIT WAIVER EASEMENT RECORD, INSTR, NO. DATE U
CITY - TEL. NO. f1
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. O
HWY. OR ST. WIDENING
so as to become subject to the Workers' Compensation Laws. ()
ML BLOCK TRACT STATE ENCROAC MENT tLLJ
L
Date L/"L/) Applicant RMIT Q�
SIZE OF LOT NOW ON LOT
NOTICE TO APPLICANT: If, after making this Certificate of / Z
v
Exemption, you should become subject to the Workers' USE OF BUILDINGS
CHARGES
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions Or this permit shall beCONTRACTOR CONNECTION CHARGE FEE
'
deemed revoked.
LICENSED CONTRACTORS DECLARATIONADDRESS UQ nREIMBURSEMENT FEE
I hereby affirm that I am licensed under provisions of Chapter DISTRICT NO. GROUP MAP NO
BY BK
9 (commencing with Section 7000) of Division 3 of the Busi- CITY TEL. PG
NO. �
ness and Professions Code, and my license is in full force and STATE LIC. (f
effect. LICENSE NO. CLASS
NO. DESCRIPTION OF WORK FEE
'y(^� HOUSE SEWER CONNECTING TO FINAL VALIDATI N
License NumberLic. Class ILLLY PUBLIC SEWER X 0 DATE Z_v
SEPTIC TANK,SEEPAGE PIT OR
Contractor LyToo.� 11/x,— U//7 Date 1` � / Vl/ PITS AND/OR GRAINFIELD
FIN�FINA
HOUSE SEWER CONNECTING TO BY
❑ '
I am exempt from the licensing requirements as I am a PRIVATE DISPOSAL SYSTEM
ONNECT 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,GRAINFIELD
iness and Professions Code). EXTN.,CESSPOOL,DRYWELL,MANHOLE
ALTER, REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
Lic.or Reg.No. Date
;2340.4A
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's OWNERS Permit s a+ # ° ° ° D 1 0
License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE ° - 2750
ness and Professions Code): IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED III-
'.RACTOR
ON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING =
I, as owner of the property, will do tlie work and the TO THE PUBLIC SEWS ° ° ° 2 7.5 0 5
structure is not intended or offered for sale (Section SIGNED THIS M DAY OF 19 gar
7044, Business and Professions Code). 1.05-!-85
OWNEROR M^' PaaX o�Q,
OWNERS AGENT ��\Y �'T, t I�
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
issued(Sec. 3097,Civ.C.). �� ` ,,v I -a-
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