HomeMy Public PortalAbout5936 HART AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self ,
insure ora certificate of Workers'Compensation Insurance, or 76A642D /� rI /�bl /� M FOR
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a certified copy.thereof(S . 3800, Lab .) 92-0002 DPW 6/66 /O\p�ll p(( /U��pOU V u Ol1U U L7 UUUV tlFT
Peli;.y No Comp ny (/-illi SEWER
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Certified copy is hereby fur ed. ` EWER a SEWAGE DOSPOS6= L
❑-Certified copy is filed wit t county building inspection COUNTY OF LOS ANGELES . BUILDING AND SAFETY
department.
Date r_Appl' ant ' ICOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM:WORKERS' BUILDING STATION & 7- DEPTH
COMPENSATION INSURANCE' ADDRESS ,
(This section need not be completed if the work involved by..the GJ MANHOLE REFERENCE LIP
permit is for one hundred dollars ($100)or less.) LocnurY d. o ER
I certify that in the performance of the work for which this NEARESST. TYPE OF CON TION LENGTH FROMCROSS +.
permit is issued, I shall not employ any person in any manner Y C B P.L. M.L.TO P.L.
so as to become subject to the Workers'Co ens tion Laws. P.C.NO.
I P. OWNER , CO.IMP.NO. JOB NO.
- r —^ MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
Date- ` Applicant ADDRESS (! vvY"'
NOTICE TO APPLICANT: 11: aft akin this Certificate Of // AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
g CITU TEL.NO. (p
Exemption, you should bec a 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 Busi- BUILDINGS CHARGES
ness and Professions Code, and my license.is in full force and 01
effect. CONTRACTOR 'CONNECTION CHARGE FEE C�]t
License Numb 34�D�PO Lic.Class / • 2' ADDRESS �u REIMBURSEMENT FEE `"
Contractor Date DISTRICT NO. GROUP MAP PROCESSED BY a
CITY Ave
STATE LIC. `` p BK PG
❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. CLASS Z'Z. �C •3 �� �p�. C� b
W
Plumbing Code and/or Sec. Of the NO. DESCRIPTION OF WORK FEEL HOUSE SEWER CONNECTING TO DATE VALIDATION
B. 8 P. Cade for the-following reason PUBLIC SEWER O —�.' _ Z
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELO FINAL
DOTe HOUSE SEWER CONNECTING TO ' BY c 6
PRIVATE DISPOSAL SYSTEM
l,.Ill
Signature - CONNECT ADDITIONAL BLDG.OR -'---- ^
WORK TO HOUSE SEWER
UIL ER DECLARATION T'r'y_
AINFIELD
I hereby affirm t I am exempt from the Contractor's License ETN.,CESSPOOL,
DRIYWELRL,MANHOLE
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE 11-I} i;_ s 0
fessions Code): SEWER OR DISPOSAL SYSTEM •, -
❑ I,as owner of the property,or my employees with wages as
their sole compensation, will do the work and the structure tV lid'as w ali-:
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permit $
❑ 1,as owner of the property,am exclusively contracting with AUTHORIZATION I TOTAL REE
licensed contractors to construct the ( 7044
S
ect j
roection , il_s},
P I-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. rs,'I •; /�
'CONSTRUCTION LENDING AGENCY D
I hereby affirm that there is a construction lending agency SIGNED THIS � 2— DAY OFd 19 i
for the performance of the work for which this permit is OWNER OR
issued (Sec. 3097, Civ. C.). OWNER
S:AGENT
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
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upon the abov entioned property for inspection purposes.
Si Permittee 05ate i SEE REVERSE FOR EXPLANATORY LANGUAGE