HomeMy Public PortalAbout4807 HALLOWELL AVE_Sewer__ r- ;YORKERS'COMPENSATION DECLARATION
'.,,1 hpreb� affirm thd�I have a certificate of consent to self
<.insure, or a tertificpte of W6rkers'Compensation Insurance, or 76A642D
a certified copy thereof (Sec. 3800, Lab C.) CE 808(REV.1/831 APPLICATION FOR PERMIT �I
Policy No. Company
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING /J�. �Q 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 LOWER
NEAREST F TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. Y. CURB P.I. M.I.TO P.L.
permit is issued, I shall not employ any person in any manner
so as to becom su ect to the Wok rs'Co a sation Laws. P.C.NO.
I P OWNER CO.IMP.NO. � JOB NO.
f 2 1 S[ MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
Date` _ (! Applicant ADD SS
NOTICE TO APPLICANT: If, after makingthis ertificate Of L AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
CIT TEL.NO. 7
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION LOT
NO.OF PERMIT NO.
SIZE OF LOT � NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter USE OF
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES
ness and Professions Code, and my license is in full for and
effect: CONTRACTOR CONNECTION CHARGE FEE
License Number Lic.Class ��7_ ADDRESS d ` REIMBURSEMENT FEE
Contractor ` r / _ DISTRICT NO. GROUP MAP PROCESSED BY O
� Date CITY EL.NO. 6'/
STAT � LIC. BK PG
❑ I am exempt under Sec. of the L.A.Co. E- 17 NO. CLASS `' (/N 0
O
Plumbing Code and/or Sec. of the No. DESCRIPTION OF WORK FEE FINAL 7�
HOUSE SEWER CONNECTING TO DATE 6�CS1 VALIDATION
B. 8, P. Code for the following reason PUBLIC SEWER OZ.
SEPTIC TANK,SEEPAGE PIT OR FINAL
PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signature - CONNECT ADDITIONAL BLDG.OR -T 4,1 2 9 A
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER /it do61
OVERW SEEPAGE I hereby affirm that I am exempt from the Contractor's License EXTNFLOESSPOOL,DRYW LL, MANHOLE # 0 0 0 0 1 0
Law for the following reason (Sectors 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM o o ,3250
❑ I,as owner of the property,or my employees with wages as =
their sole compensation, will do the work and the structure o 0 0 3 2 5 05
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permit $ Q 0 2 2 7°.`8 6
❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE
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 DESCRIBE�ISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY ,
I hereby affirm that there is a construction lending agency SIGNED THISJ=
— Z•7 DA 19_
for the performance of the work for which this permit is OWNER
issued (Sec. 3097, Civ. C.). OWNERS A AGENT
ADDRESS' d ��
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 h reby authorize representatives of this County to enter
U
p a abo e- ntioned property for inspection purposes.
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lab
Signature'of Perryffttee Date SEE REVERSE FOR EXPLANATORY LANGUAGE