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HomeMy Public PortalAbout4820 HALLOWELL AVE_Sewer__ '~WORKERS'COMPENSATION DECLARATION 1�bereby affirm that I have a certificate"of consent to self � insure;►or a,certificate of Workers'Compensation Insurance, or 76A642D a certe.ied-cony thereof (Sec. 3800, Lab C.) CE808(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' [NEAREST ILDING en O //Q/o`er �y�• STATION f DEPTH COMPENSATION INSURANCE DRESS d L �J G CY v (This section need not be completed if the work involved by the _7 YH _ MANHOLE REFERENCE D�+� UPPER permit is for one hundred dollars ($100)or less.) CALITY / LOWER TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this OSS ST. LJ Y. CURB P.L. M.L.TO P.L. permit is issued, I shall not employ any person in any manner subject to the Workers' ensation Laws. P.C.No. so as to become sub I P OWNER CO.IMP.NO. � Z JOB NO. MAIL TRUNK PERMIT NO. ROAD PERMIT NO. Date.il(- *Applicant ADDRESS �� NOTICE TO APPLICANT: If, after makingthis Certificate of // AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE CITY TEL.NO. b 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 TSE 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. CONTRACTOR CONNECTION CHARGE FEE License Number Lic.ClassADDRESS REIMBURSEMENT FEE P. Contractor - Date - DISTRICT NO. GROUP SK PROCESSED BY CITY TEL NO. K G ❑ 1 am exem t under Sec. of the L.A.Co. STATE LIC. `/fig _ O P - LICENSE NO. CLASS (f NO. DESCRIPTION OF WORK FEE Plumbing Code and/or Sec. of the F N(� HOUSE SEWER CONNECTING TO DA VALIDATION @y B. & P. Code for the following reason PUBLIC SEWERSEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR O ► OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER I hereby affirm That I am exempt from the Contractor's License OVERFLOW SEEPAGE PIT,DRAINFIELDEXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Secton 7031.5, Buisness and Pro- SEWER RE DISPOSAL OSALBANDON HOUSE t fessions Code): AI,as owner of the property,or my employees with wages as ACCT°a their sole compensation, will do the work and the structure "R is not intended or offered for sale (Section 7044, Business Permit $ ,3307 �i°c and Professions Code). OWNER'S ❑ 1,as owner of the property,am exclusively contracting with AUTHORIZATION I TOTAL FEE 1 ITEMS TOTAL licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO !OTAL 2 1 . To Business and Professions Cade). CONNECT THE ABOVE DE RIBED EXIS ING DWELLING TO THE PUBLIC SEWER. �+.4W//`` '—a CONSTRUCTION LENDING AGENCY 21° 0 • "5' I hereby affirm that there is a construction lending agencSIGNED THIS c y p���'�0 4 19_ A�� for the performance of the work for which this permit is OWNER OR �•H1INGE °00 issued (Sec. 3097, Civ. C.). OWNERS AGENT ADDRESS 91, Lender's Name 0000-0001 8/17/9,9 Lender's Address 1 certify that I have read this application and state that the ���� AM 3 4 above information is correct. I agree to comply with all County ordinances and State laws regulating Plumbing and Sewers, and hereby thorize representatives of this County to enter upon ve-me ne�pe�inspection purposes. Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE