HomeMy Public PortalAbout4817 HALLOWELL AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
hereby affirm that I have a certificate of consent to self 76A642 DPW 3/87
insure,•or a certificate of Worker o nsation Insurance, or 76A642D
ci certifie y d (Sec. 380 C. CE 808 APPLICATION FOR PERMIT
Policy N Company �Os
❑ Certified copy is hereby furnished. ✓ SEWER - SEWAGE DISPOSAL
Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
depara�t 9
Date Applicant 2?1, �. FOR APRLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING �1 r STATION DEPTH
COMPENSATION INSURANCE ADDRESSUPPER
�� �yLGOGIrJ G c-
(This section need not be completed if the work involved by the LOCALITY — /JG �r MANHOLE REFERENCE OWER
permit is for one hundred dollars ($100)or less.) /�
NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST.
Y. CURB 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' Compensation Laws. OWNER � Z-<— CO.IMP.NO. JOB NO.
TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRES /l/
NOTICE TO APPLICANT: If, after making this Certificate of C�V �� "too. ;21A
/ // AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
40
Exemption, you should become subject to the Workers' LEGAL O�
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 PERMIT NO.
LOT
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 force and ,
effect. �9 7�� �/� CONTRAC �J� �j��D/(�� /vS CONNECTION CHARGE FEE
License Numb / 7 LIC.CIpSS REIMBURSEMENT FEE 0.
�i ADDRES e �� (�J+
Contractor/%����41C Date /� CIT�G ///(ice�� TEL.NO. DISTRICT NO. GROUP MAP PROCESSED BY O
STATE /y LIC.
El �
s _ BK PG
I am exempt under Sec. of the L.A.Co. LICENSE NO. O CLASS y 2 0
NO. DESCRIPTION OF WORK FEE
Plumbing Code and/or Sec. of the j HOUSE SEWER CONNECTING TO DA EL VALIDATION LU
LU
B. & P. Code for the following reason / PUBLIC SEWER U)
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD FINAL
Date HOUSE SEWER CONNECTING TO BY
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 (Sefton 7031.5, BUisness and Pro- ALTER,REPAIR OR ABANDON HOUSE L?
fessions Code): SEWER OR DISPOSAL SYSTEM ACC
t rR• a
❑ I,as owner of the property,or my employees with wages as (��{ l o
their sole compensation, will do the work and the structure .54 .-.Ll
is not intended or offered for sole (Section 7044, Business
and Professions Code). OWNERS Permit $ 'p ITEMS
❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE 13,H-5-0 -;s•- 34 = 50
licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO €t
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. i, '
'4�=IIS
CONSTRUCTION LENDING AGENCY fis
SIGNED THIS /� DAY OF 19 , CHAIt'-E i 11 I
I hereby affirm that there is a construction lending agency CHAINGE -for the performance of the work for which this permit is OWNER OR /
issued (Sec. 3097, CIV. C.).
OWNERS AGENT 7 L7
ADDRESS
Lender's Name J.&,'+-°i?
Lender's Address 3799 99 I Art 1�� `
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,
ano hereby authorize representatives of this County to enter
uPion the ab ov -mentioned property for inspection purposes.
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE