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HomeMy Public PortalAbout6012 HART AVE_Sewer__ WORKERS'COMPENSATION DECLARATION I hereby affirm that n have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance, or 76A642D .d:, CE 808(REV.8/81) a�c�ejrtyfi�e o thereof (Sec. ny t La t fes_ ©S /p\����� ��Of�fl [�Of7 ��2(6�11(1�� PoPfc �70 ���Com. , q— �� z [r� rr����pppp2r�rrao��/r�1 ��ppppl1V [12 IJ�2 ISINIIpVII ❑ Certified copy is hereby furnished. SEWER SEWAGE MSPOSAL Certified demco y is filed with the county building inspection _ COUNTY OF.LOS ANGELES BUILDING ARID SAFETY p aen . Date %;` �� Applicant FOR APPLICANT TO FILL IN CONNECTION DATA- CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING ��' STATION DEPTH COMPENSATION INSURANCE ADDRESS This section need not be completed if the work involved b the UPPER ` ( P Y "s MANHOLE REFERENCE. ' permit is for one hundred dollars'($100)or less.) LOCALITY rj / �- LOWER NEAREST _ TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST. dr� � _ Y. . CURB P.I. 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 CO.IMP.NO. JOB NO; MAIL TRUNK PERMIT NO. ROAD PERMIT NO. " Date Applicant ADDRESS NOTICE, TO APPLICANT: If, after makin this Certificate Of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE g CITY � TEL.NO. Exemption, you should become subject to the Workers' LEGAL `I Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. 1 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 1 am licensed under proyisions 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. CONTRACTOR �' rt yZ _ /� CONNECTION CHARGE FEE >, License Number LIC.Class ADDRESS �! �� `� �� l' �'`.�/�� REIMBURSEMENT FEE O !� DISTRICT NO. GROUP MAP PROCESSED BY Contractor Date CITY r-�rt ' TEL NO. / / 7--�` BK PG - ❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. - LIC. > '� �L NO. DESCRIPTION OF WORK FEE U Alit J Plumbing Code and/or Sec. of the FINAL TELU HOUSE SEWER CONNECTING TO DATE VALID ION 0. B. & P. Code for the following reason PUBLIC SEWER - . SEPTIC TANK,SEEPAGE PIT OR FINA g PITS AND/OR DRAINFIELD e Date HOUSE SEWER CONNECTING TO B 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- REPAIR OR ABANDON HOUSE fessions Code): SEER 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 is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S Permit $ y ❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE 6 7.1.8 A licensed contractors 10 construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO #.O O O O 1 O Business and Professions.Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. ' CONSTRUCTION LENDING AGENCY I o 2.1,5 0 I hereby affirm that there is a construction. lending agency SIGNED THIS DAY OF 19_ _ for the performance of the work for which this permit is OWNER OR O o O 2 1. 5 OAU issued (Sec. 3097, CIV. C.). OWNERS AGENT 2 3=8 7 ADDRESS .O 3. 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 above-mentioned property for inspe�ctiio o•pureose . �/ice� �-_� .i '�/1S •� - Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE