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HomeMy Public PortalAbout6109 HART AVE_Sewer__ WORKERS'COMPENSATION DECLARATION n r 1'hvrebv''affirm•that I have a certificate of consent to self .. - f§'Isure, era certificate of Workers'Compensation Insurance;.or 76n642D 8:cerWied 66py"thereof (Sec. 3800, Lab C.) 92.00.02 DPW 6,99. AcyNg * Company a Ce tified copy,is.hereby furnished. SEWER SEWAGE DOSPOSAL , °MC-ertified 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 EXEMPTIO .F OM WORKERS. euuDwG' ,.,!, � �_ STATION �� DEPTH COMPENSATION INSURANCE ADDRESS f (This section need not be completed if the work involved by the., =�� C -� MANHOLE REFERENCE E permit is for one hundred.dollars.($1.00)-or less.) LocnPTv I certify in the NEAREST, TYPE OF CO ON LENGTH FROM:.. y performance of the work for.which this CROSS ST ^�"� Y. CURB' P.L. M.L.TO P.L. perrTiit is issued, I shall not employ any person in any manner, so alto become subject to the Workers'Compensation Laws. JOB NO. OWNER- CO.IMP.NO. ) JOB NO. t� MAIL TRUNK PERMIT NO. ROAD PERMIT NO. Dote , c A Iicant ADDRESS Q o ,L vC: �'-, ,4 , PP,•. AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTICE TO 'APPLICANT:' If, after. .king this Certificate of. CITY TEL:NO.7/d, JZ Exemption you , hould become subject to the Workers' iecai Compensation provisions of the Labor code, you must forthwith DESCRIPTION - LOT NO. HWY.ORST.WIDENING comply with such provisions or this permit shall be deemed revoked. - BLOCK TRACT STATE ENCROACHMENT NO.OF BLDGS. PERMIT NO. LICENSED'CONTRACTORS DECLARATION SIZE OF LOT NOW ON Lor I hereby affirm that I am'licensed under provisions of Chapter USE OF 9 (commencing with Section:2000) of Division 3 of the BU51- BUILDINGS CHARGES ness and Professions'Code, and'my license is in full.force and . -effect., _ _ - CONTRACTOR CONNECTION CHARGE FEE , /y License Number �< r Lic..Closs' REIMBURSEMENT FEE `8 ADDRESS � �� - - - •� � � _ -Contractor Date-1, y DISTRICT NO..- GROUP ':. MAP PROCESSED BY ` .. CITY _ TEL.NO. BK PG ❑ lam exem t.urnder Sec. of the L.A:Co. STATE ue., ©p P LICENSE NO.. CLASS `� DESCRIPTION OF WORK FEE- Plumbing Code and/or Sec. of the NO. FINAL 11:' HOUSE.SEWER,CONNECTING TO - DATE PUBLIC SEWER VALIDATION - ,.2 G�, B. 8 P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR PITS AND/.OR DRAINFIELD FINAL Date _ HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM - - Signature - CONNECT ADDITIONAL BLDG.OR - - - OWNER- UIL R 6ECLARATION, ' WORK TO HOUSE SEWER TOVERFLOW SEEPAGE PIT,DRAINFIELDhereby affirm that I am exempt from the Contracto'r's License EXTN.,CESSPOOL,DRYWELL,,MANHOLE 7,i Law for the following reason (Secton 7031.5; Bujsness and Pro ALTER,'REPAIR OR ABANDON HOUSE fesslons Code): SEWER OR DISPOSAL=SYSTEMS;o4 ' I,as,owner of the property,or employees with wages>as their sole compensation, will do the work and the structure •. ` is not intended or offered for sale (Section 7044,;Business L,-'t= and Professions Code). OWNER'S Permit' g 3 � �IL.tFw EJ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL F(~E TOTAL •�4 x.50 licensed contractors to'construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO ti Business and Professions Code). - CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CHECK CONSTRUCTION LENDING AGENCY �;�{r�i �_ ,1 I 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 OWNERS AGENT yy tt,, ••LL •• v j_ ` issued (Sec. 3097, Civ. C.). ADDRESS (wi(�f11t3'L 'q_)3 ' J �J as , Lender's Name y Lender's Address 442..E s E� 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 'bo a-me'tinned property for inspection purpJoses. Signatu e of Permittee Date t SEE REVERSE FOR EXPLANATORY LANGUAGE