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HomeMy Public PortalAbout5646 HALLOWELL AVE_Sewer__ WORKERS'COMPENSATION DECLARATION I Hereby affirm thar I have a certificate of consent to self 76A64292-0002 DPW 3/87 insure,or ci certjficate of Workers'Compensation Insurance, or CE 808 D a certified co thereof, Sec. 3800, Lab C. 0 0 0 0 0 Policy No. PYo Company 577�1F fyv� ®s apppdp�pC� U ON FOR pC�Q�in1� H. ertified copy Is,hereby furnished. SEWER - SEWAGE ©OSPOSAL -Sce'rtified copy is filed with.the ount buildi g inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY, departm nt. = - Date2Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTIO O ---^' BUILDING // r COMPENSATION INSURANCE ADDRESSV . mob ( fN �(� STATION DEPTH /© (This section need not be completed if the work involved by the MANHOLE REFERENCE ` PPER permit is for one hundred dollars ($100)or less.) LOCALITY LOWER NEAREST - TYPE OF CONNECTION LENGTH FROM 1 certify that in the performance of the work for which this CROSS ST. L4 Y. CURB P.L. M.L.TO P.L. / permit is issued, I shall not employ anyperson in any manner � , J J y� P.C.NO. so as to become subject to the Workers' Compensation Laws. OWNER . 11 N CO.IMP.NO. JOB NO. Date Applicant ADMAILDRESS TRUNK PERMIT NO. ROAD PERMIT NO. • AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTICE TO APPLICANT: If, after making this Certificateof CITY TEL.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 ' i - 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 ;I it f� effect. �Z CONTRACTOR CONNECTION CHARGE FEE ^ License Number !;(5'Y7T3 Lic.Class /� ` ADDRESS REIMBURSEMENT FEE d Contractor .r/� Gh(!•:/.4�Date DISTRICT NO. GROUP MAP I(3 PROCESSED BV y ". CITY TEL.NO. OUP LIC. BK _ ❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. CLASS / r -0 zif . 3 > � . NO. DESCRIPTION OF WORK FEE :,•:1ty_�.. ,? ' Plumbing Code and/or Sec. ofthe FINAL HOUSE SEWER CONNECTING TO DATE ` VALIDATION ILJ B. & P. Code for a Ilowing r aSon PUBLIC SEWER N SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIELD i"3'i?+E��•: `. Date BY - HOUSE SEWER CONNECTING TO - PRIVATE DISPOSAL SYSTEM =; - ' Signature _. CONNECT ADDITIONAL BLDG.OR D .:.L4 -• A'�•S°-=`��= O - N WORK TO HOUSE SEWER SEEPAGE INFIELD I hereby affirm that I am exempt from the Contractor's License EOTNFLOCESSPOOL,DRYWDRAMAN OLE Law for the following reason (Secton 7031.5, Bulsness and Pio- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM I� I,as owner of the property,or my employees with wages as their sole compensation,will do the work and the structure - Is 'ot intended or offered for sale (Section 7044, Business Professions Code). OWNER'S Permit $ 07 7 I, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE 3 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 DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY D I hereby affirm that there is a construction lending agency OWNER SIGNED THIS DAY OF 19_ for the performance of the work for which this permit is OWNERSAGENT issued (Sec. 3097, Civ. C.). ADDRESS Lender's Name Address t I have read this application and state that the tion is correct. I agree to comply with all County State laws regulating Plumbing and Sewers, rize representatives of this County to enter ntioned property for inspectio purposes. 00 Date SEE REVERSE FOR EXPLANATORY LANGUAGE