HomeMy Public PortalAbout11026 GREEN TREE LN_Sewer__ ' * WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self jl
insure, or a certificate of Workers'Compensation Insurance, or 76A642D U
a certifie o y there f (Sec. 38 Lab C., 1 CE 808iREV.I/831 APPLICATION FOR PERMIT
Policy No �ompany (1 QA1�hU C, 7._rc�enly�,�
SEWER - SEWAGE DISPOSAL
Certified copy is hereby furnished. \
El
❑ Certified copy is filed with the county building inspection
COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Date —Applicant `� r(1aK_V('+, )e�. FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION DEPTH
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the Work involved by the MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY (OWER
NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. Y. CURB P.I. M.L.TO P.L.
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers Compensation Laws. P.C.NO.
I P OWNER � A CO.IMP.NO. JOB NO.
MAIL 1 TRUNK PERMIT NO. ROAD PERMIT NO.
Dote Applicant_ �y �� ADDRESS L
this Certificate of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
NOTICE TO APPLICANT: If, after making CITU � TEL.NO.
Exemption, you should become subject to the Workers' LEG L
Compensation provision's of the Labor code, you must forthwith DESCRIPTION LOT NO. 7 HWY.OR ST.WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT STATE ENCROACHME
LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO.
SIZE OF LOT NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter USE OF `
S IUY
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES
ness and Professions Code, and my license is in full force and
effect. C CONTRACTOR CONNECTION CHARGE FEE
License Number ic.Class ( REIMBURSEMENT FEE
y�y� 2:2-
J �J ADDRESS
Contractor 1 L �q.. � Date �� Lr(sem 44 �"� DISTRICT NO. GR UP MAP {2 ESSED BY 0
CITY A rn, TEL.NO. BK PG / �
❑ I am exempt under Sec. of the L.A.Co. STATE CLLIC / ��//
P LICENSE NO. CLASS ��V
129
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL
pHOUSE SEWER CONNECTING TO DATE VALIDA ON
B. 8 P. Code for the following reason J PUBLIC SEWER �
SEPTIC TANK,SEEPAGE PIT OR 9L
PITS AND/OR DRAINFIELD FI gn
Date HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM -
Signature CONNECT ADDITIONAL BLDG,OR Poo.DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD
I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE
Law for the following reason (Secton 7031.5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM
❑ I,as owner of the property,or my employees with wages as
93.4a5A
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business # o 0 0 0 Q
and Professions Code). OWNERS Permit $
El 1,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE J o o27.50
licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO =
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. o27,50
U
CONSTRUCTION LENDING AGENCY C^C �� , 1.05-85
1 hereby affirm that there is a construction lending agency SIGNED THIS 9 7- DAY OF J 19
for the performance of the work for which this permit is OWNER OR
issued (Sec. 3097, CIV. C.). OWNERS AGENT , 5�)x ? n
ADDRESS an he r
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.
X-(-\ �� 1�- 2
Si nature o Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE