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HomeMy Public PortalAbout4816 HALLOWELL AVE_Sewer__ WORKERS'COMPENSATION DECLARATION hereby=affirm that I have a certificate of consent to self .I sure, or a certificate of Workers''Co'mpensation Insurance, or 76A642D ,3 certified copy thereof (Sec. 3800, Lab C,, CE 808(REV 8/81) APPLICATION FOR PERMIT Policy No. Company ©s ❑ 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� ) J STATION 'JS", DEPTH / / COMPENSATION INSURANCE ADDRESS Lam(/(/ (Y(� OOO�GG. , l✓ This section need not be completed if the work involved b the U ( P Y �� MANHOLE REFERENCE permit is for one hundred dollars ($100)or less.) LOCALITY 'f-5Os OWER NEARESTIF TYPE OF CON LECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST. Y. CUR P.L. 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' Com ensatio LOWS. P.C.No. I P OWNER 6 ^ili W f CO.IMP.NO`, JOB NO. MAIL TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant 11 /CGJ�O ADDRESS (�a) k* this Certificate O{ AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTICE TO APPLICANT: If, after ma dg CITY' EL NO. 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 NO,OF BLDGS. 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 Bu Si- BUILDINGS CHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTOR CONNECTION CHARGE FEE License Number Lic.Class ADDRESS REIMBURSEMENT FEE O Contractor Date DISTRICT NO. GROUP MAP �CESSED BY CITY TEL.NO, LBK PG / � ❑ I am exempt under Sec. of the L.A.Co. STATE CLLICPP � y O P LICENSE NO. CLASS I D � /. �� Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL - U HOUSE SEWER CONNECTING TO DATE VALIDATION B. & P. Code for the following reason PUBLIC SEWER N SEPTIC TANK,SEEPAGE PIT OR FINAL g PITS AND/OR DRAINFIELD e Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM \ Signature CONNECT ADDITIONAL BLDG.OR , OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER I hereby affirm that I am exempt from the Contractor's License OVERFLOW ETN.,CESEEPAGE SSPOOL,DRYWDRAMANHOLE Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM 33 ^ C fessions Code): ��I�7 1�,e.t0 I,as owner of the property,or my employees with wages as 1 ITEMS their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business Permit $ TOTAL 21 =50 and Professions Code). OWNERS ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE ( CHECK 21.50 licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO CHANGE � � Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF19_ r 89 for the performance of the work for which this permit is OWNEROWNERS AGENT 003-001010f 8/25 issued (Sec. 3097, Civ. C.). , U e ADDRESS _t18 1 AM11osj70 Lender's Name C3 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 r pre tatives of this County To enter up o the ab e-menti a pr per6 for inspect* n purp ses. Signature of P rmlttee Date SEE REVERSE FOR EXPLANATORY LANGUAGE