HomeMy Public PortalAbout11025 GREEN TREE LN_Sewer__ NVOR KERS'COMPENSATION DECLARATION 76A642D APPLICATION FOR PERMIT
CE 808 (2-80)
'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 certified ^o the e f(Sec. 38g Lab.C.) ,y COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No.�J�ompany�� 3 k Lo) nl) l
El Certified copy is hereby furnished. FOR APPLICANT TO FILL IN CONNECTION DATA
BUILDING STATION DEPTH
Certified co is filed with the count building woDREss
copy y g inspection UPPER
Datede artment. j\ �/'�,,� LOCALITY MANHOLE REFERENCE LOWER
Applicant �k 1( r) r 11 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 t TRUNK PERMIT NO. ROAD PERMIT NO. }
by the permit is for one hundred dollars ($100) or less.) a
CITY TEL. N
•' AFFIDAVIT WAIVER EASEMENT RECORD, INSTR. NO. DATE 0
� O. � 7�
I certify that in the performance of the work for which this LEGALf V
permit is issued, I shall not employ any person to any manner DESCRIPTION LOT NO. 6 HWY. OR ST. WIDENING X
so as to become subject to the Workers' Compensation Laws. 0
.^' '�,,/� BLOCK TRACT STATE ENCROACHMENT V
�0 pp �I C `_nC CMY y�— PERMIT NO.
Date,f�r�Applicant `�y_\y�L..-.`i \ �L.� IJ U. OF BLDGS.
SIZE OF LOT NOW ON LOT
NOTICE TO APPLICANT: If, after making this Certificate of O_
xemption, you should become subject to the Workers' USE OF CHARGE
'ompensation provisions of the Labor Code, you must forth- BUILDINGS Z
Ith comply. with such provisions or this permit shall be CONTRACTOR CONNECTION CHARGE FEE
eemed revoked.
LICENSED CONTRACTORS DECLARATION ADDRESS / REIMBURSEMENT FEE
hereby affirm that I am licensed under provisions of Chapter l DISTRICT NO. GROUP MAP PR C SSE.BY
i (commencing with Section 7000) of Division 3 of the Busi- clTv TEL. No. BK PG
ness and Professions Code, and my license is in full farce and STATE Jl
LICENSE NO. CLASS s+l VVV111
effect.
NO. DESCRIPTION OF WORK FEE '
�(?'[y/( HOUSE SEWER CONNECTING TO FINAL VALIDAT N
icense Numbers 1`S4 "7,_')(D-Lic.Class ( PUBLIC SEWER DATE _C�
SEPTIC TANK,SEEPAGE PIT OR 'tel
Contractor Max-ya A��p. Date
PITS AND/OR DRAINFIELD
FIN
HOUSE SEWER CONNECTING TO B
❑ 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 /051, Bus- OVERFLOW SEEPAGE PIT, DRAINFIELD
iness and Professions Code). EXTN.,CESSPOOL.DRYWELL, MANHOLE
ALTER,REPAIR OR ABANDON HOUSE 3 4 Q, A
SEWER OR DISPOSAL SYSTEM {
Lic,or Reg.No. Date # 0 0 0 0 0
HOME OWNER-BUILDER DECLARATION I ° o 2 7,5 0
I hereby affirm that I am exempt from the Contractor's OWNERS Permit E 0 0 O 2 7.5 0 5):
License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE
ness and Professions Code): > �, �,d 5_8 5
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON'
❑ 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 is not intended or offered for sale (Section SIGNED THISDAY OF ,1, 19
7044, Business and Professions Code). LADDR`-',S-^Q'
NER OR ,ry,
CONSTRUCTION LENDING AGENCY l�C 1 � ai
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.). \ ����� 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
Signature of Permittee Date