The URL can be used to link to this page

Home My Public Portal About6116 HART AVE_Sewer__ .- WORERS'CC YENSATION DECLARATION D I CE 808 (2-80) APPLICATION F® es PERMIT I hereby affirm that Ohave a certificate of consent to self SEWER-SEWAGE DISPOSAL insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800, Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN CONNECTION DATA BUILDING �f /t '�" STATION DEPTH Certified copy is filed with the county building inspection ADDRESS //-r -J� I UPPER department. LOCALITY rt tw to c r( � MANHOLE REFERENCE LOWER Date Applicant NEAREST TYPE OF CONNECTION LENGTH FROM CERTIFICATE OF EXEMPTION FROM WORKERS' cRoss ST. Y. CURB P.L. M.L. TO P/C. COMPENSATION INSURANCE �()j h 7 kp( P.C. NO. OWNER /7/ C o� A 1 L ', I♦ O CO. IMP. NO. JOB NO. MAIL �/ (This section need not be completed if the work involved ADDRESS /y q jV, l/ _r rj TRUNK PERMIT NO. ROAD P RMIT NO. >- by the permit is for one hundred dollars ($100) or less.) a �/{.� AFFIDAVIT 9 Ire- WAIVER EASEMENT RECOR . INSTR.NO. DATE O CITY / '� / L. NO. Ia I certify that in the performance of the work for which this LEGAL U permit is issued, I shall not employ any person in any manner DESCRIPTION LOT NO. HWY. OR ST. WIDENING (r so as to become subject to the Workers' mp sation ws. t0 J/lye/g,/�� j,��, BLOCK TRACT STATE ENCROACHMENT �- ,<Date Applicant ✓ //rf� i S�rVW� V NO. OF BLDGS. PERMIT NO. W SIZE OF LOT g r + NOW ON LOT NOTICE TO APPLICANT: If, after making this Certificate of Q Exemption, you should become subject to the Workers' BUIEOF LD NGSCHARGES Z Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall beCONNECTION C RGE FEE deemed revoked. CONTRACTOR REIMBURSE NT FEE LICENSED CONTRACTORS DECLARATION ADDRESS I hereby affirm that I am licensed under provisions of Chapter CITY TEL. NO. PG DISTRICT NO. GROUP MAP PRo ESSED BY BK 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full force and STATE LIC. 6—,e JV, LICENSE NO. ✓ CLASS effect. NO. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO FINAL �J VALIDATION License Number Lic.Class PUBLIC SEWER DATE (— SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD Contractor Date FINAL HOUSE SEWER CONNECTING TO BY ❑ PRIVATE DISPOSAL SYSTEM ' am exempt from the licensing requirements as I am a CONNECT ADDITIONAL BLDG.OR licensed architect or a registered professional engineer WORK TO HOUSE SEWER acting In my professional capacity (Section 7051, BUS- OVERFLOW SEEPAGE PIT,DRAINFIELD Iness and Professions Code). EXT..,CESSPOOL,ORYWELL,MANHOLE ALTER, REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's OWNER'S Permit 8 Q License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE G ness and Professions Code): I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- TRACTOR TO CONNECT THE ABOVE DESCRIBED E%ISTING DWELLING ID I, as owner of the property, will do the work and the TO THE PUBLIC SEWER. D' structure is not intended or offered for sale (Section SIGNED THIS DAv OF 19 z 4 4 0,b A 7044, Business and Professions Code). owNER oR }{ OWNERS AGENT # 070 D O 1.0 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency ADDRESS 10 0 1 ,75 0 for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). D)0,0 1 7. 5 0-H Lender's Name Lender's Address +6 1 7'-82 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 abo�ve�- entione`d proper,yy,//f�orr, inspection purposes. z`V�' SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date