HomeMy Public PortalAbout5569 HALLOWELL AVE_Sewer__ plORKERS'COMPENSATION DECLARATION
firm that I, have a certificate of consent to self
certificate of Workers'Compensation Insurance, or 76A6420
a certified copy thereof (Sec. 3800, lab C.) 92-0002 DPW 6/68 APPLICATION FOR PERMIT
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 `� (� STATION 1—�.� b DEPTH
COMPENSATION INSURANCE ADDRESS ( // L
(This section need not be completed if the work involved by the MANHOLE REFERENCE /7� �j Q LUPPER
OWER
permit is for one hundred dollars ($100)or less.) LOCALITY
NEAREST TYPE OF CONNECTION LENGTH FROM
1 certify that in the performance of the work for which this CROSS ST. �V�tr O �- 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 P.C.NO.� CO.IMP.NO. JOB NO.
MAILi d-ee TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS QS
NOTICE, TO APPLICANT: If, after makin this Certificate Of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
g CITY TEL.N0.
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.
1 hereby affirm that I am licensed under provisions of Chapter SIZE OF LOT NOW ON LOT
usE of
9 (commencing with Section 7000) of Division 3 of the Busl- BUILDINGS CHARGES
ness and Professions Code, and my license is in full force and
effect. CONTRACTOR CONNECTION CHARGE FEE [�]j
License Number Lic.Class ADDRESS REIMBURSEMENT FEE v
Contractor Date CITY _ TEL.NO. DISTRICT NO. GROUP BK MAP PROCESSED BY z
PG
STATE LIC v0 _
El am exempt under Sec. of the L.A.Co. LICENSE No. LIC. Q �1 S
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE LLI
FINAL VALIDATION
HOUSE SEWER CONNECTING TO DATE
PUBLIC SEWER y
B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR / FINAL
PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER 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, BUisness and Pro- ALTER,REPAIR OR ABANDON HOUSE S'
fessi0 Code): SEWER OR DISPOSAL SYSTEM a.t_
AP.'•';
1,as owner of the property,or my employees with wages as `-t
their sole compensation, will do the work and the structure n'7
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permit $ T-;
AUTHORIZATION
❑ I,as owner of the property,am exclusively contracting with TOTAL FEE
licensed contractors to construct the4
0
ro ect Section 74 , ',I)
P I ( I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONT ACTOR TO s
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY n• li
�
I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19 ,; jfHs{'a n h
for the performance of the work for which this permit is OWNER OR
OWNERS AGENT
issued (Sec. 3097, Civ. C.).
ADDRESS
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
ordUby
ate laws regulating Plumbing and Sewers,
andrize representatives of this Cou ty to enter
upentioned pro rty for inspection urp "es.
mittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE