HomeMy Public PortalAbout6117 HART AVE_Sewer__ WORKERS'COMPENSATION DECLARATION 76A642D
APPLICATION-80) FOR PERMIT
, , CE 808 (2 ,
> I hereby affirm that I have a certificate of consent to self SECtl ER-SEWAGE DISPOSAL
insure, or a certificate of Workers'Compensation Insurance,or
a certifi c ���y((��t f(Sec. 380, L b.C. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy I Ct4_WD/ Company Ietna.}Ins.
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN CONNECTION DATA
BUILDING z STATION ®� ,( L.� DEPTH
Certified copy is filed with the county building inspection ADDRESS 6.1,`1 Hart: �y � PPER
depaim jlo MANHOLE REFERENCE
Date (SJ2 Applica en Bros.:Pltmibi LOCALITY I 1 i ����O j� LOWER
NEAREST TYPE OF CONNECTIONG H'FROM
L
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. Y, CURB P.L. .L. TO P.L.'
COMPENSATION INSURANCE }}} �// P.C. O,
OWNER /✓ M -r;l. Gillet-l.- � CO. IMP. NO. r/C- JOB NO.
MAIL - JM
(This section need not be completed if the work Involved ADDRESS141 E- TRUNK PERMIT NO. ROAD PERMIT NO. �d
by the permit is for one hundred dollars ($100) or less.) AFFIDAVIT WAIVER EASEMENT RECORD, INST R. NO. DATE
CITY TEL. NO.. 8 - 0
I certify that in the performance of the work for which this LEGAL
permit is issued, I shall not employ any person in any manner DESCRIPTION LOT NO. HWY. OR ST. WIDENING tr
so as to become subject to the Workers' Compensation Laws. 0
BLOCK TRACT STATE ENCROACHMENT
Date Applicant NO. OF BLDGS. PERMIT NO. (�
SIZE OF LOT, NOW ON LOT W
NOTICE TO APPLICANT: If, after making this Certificate of iL
Exemption, you should become subject to the Workers' USE OF in
BUILDINGS CHARGES Z
Compensation provisions of the Labor Code, you must forth-
With comply with SUCH provisions Or th1S permit shall be CONNECTION CHARGE FEE
deemed revoked. CONTRACTOR
REIMBURSEMENT FEE
y LICENSED CONTRACTORS DECLARATION ADDRESS 42.65 N. Baldwin Ave.
I hereby affirm that I am licensed under provisions of Chapter . TEL. NO. 4..3. BK PG
'0078DISTRICT NO. GROUP MpP PR ESSED BY
. 4,. ' ..
9 (commencing with Section 7000) of Division 3 of the Busi-
CITY tl Monte.
ATE: Lie.
ness and Professions Code, and my license is in full force and LICENSE NO. CLASSC36-20
effect. NO. DESCRIPTION OF WORK FEE
1/1, r/� HOUSE SEWER CONNECTING TO A FINAL —/O_�O VALIDATION
License Number 231 741 LIC.Class`"3"-20 PUBLIC SEWER V DATE _?0
9/23/80 SEPTIC TANK,SEEPAGE PIT OR
Contracawen Bros.Plb?. Date PITS AND/OR DRAINFIELD
FINAL
HOUSE SEWER CONNECTING TO
❑ BY ��-
PRIVATE DISPOSAL SYSTEM
I 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 m my professional capacity (Section %OSI, BUS- OVERFLOW SEEPAGE PIT,DRAINFIELD
(ness and Professions Code). EXTN„CESSPOOL,DRYW ELL• MANHOLE
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
Lie.or Reg.No. Date
• 4
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's OWNER'S Permit S
License Law for the following reason (Section.7031.5, Busi- AUTHORIZATION TOTAL FEE Afoul 2!.2.2.3.4 A
ness and Professions Code): IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
T
TO CONNECT THE ABOVE DESCRIBED EXISTING DWEOLING #'10,0-.Oro 11 0,
I, as owner of the, property, will do the work and the TO THE PUBLIC SEWER.
structure is not intended or offered for sale (Section SIGNED THIS DAY OF ts_ 2 p'p O 0
704.4, Business and Professions Code). OWNER OR
' OWNERS AGENT
CONSTRUCTION LENDING AGENCY °'O °
ADDRESS
I hereby affirm, that there is a,construction lending agency
for the performance of the work for which this permit is 0 9.2 3-8 0
issued(Sec. 3097,Civ.C.).
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 th a ov tioned propert for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
9/23/80
ignature Permittee Date