HomeMy Public PortalAbout6202 HART AVE_Sewer__ WORf,I�RS ON DECLARATION
y alrrirffi th r ate of consent to self jl
or certificate f pensation Insurance,.or 76A642D n (�� FOR,
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❑ lifted copy is hereby furnislied. SEWAGE DOSP®SAL
Certifie copy is filed with the c unty buildin ins ection COUWTY OF LOS ANGELES BUILDING AND SAFETY
de or t.
Ddt - Ijc FOR APPLICANT YO FI IN C011IIbECTIOItI DATA
CERT ICATE OF EXEMPTION FROM WORKERS' BUILDI DEPTH
COMPENSATION INSURANCE ADDR S 0 /3:6
(Tflis.sect i0 need not be completed if the work involved by the _ MANHOLE REFERENCE 7��oi1J PPER
permit�is f r one hundred dollars ($106)or less.) Locnury J.sU L
NEAR .� TYPE OF CONN N LENGTH FROM
I certify that,in the performance of the work for which this CRO __ Y. RB P,I. M.I.TO P.L.
permit is issued, I shall not employ anyperson in any manner
' so as to become'subto the Workers' Com ensation Laws. P.C.NO. -
I P OWNER CO.IMP.NO. JOB NO.
MAIL V TRUNK PERMIT NO. ROAD PERMIT NO.
Date Appl.ieaADDRESS
NOTICE TO APPLICANT:.If;nt after making this Certificate Of °CITY AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO: DATE
Exemption, ,you shouldbecome subject to ,the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HW,Y OR ST.WIDENING
comply with such provisions or this permit shall be deemed
revoked. . ' ' . BLOCK TRACT STATE ENCROACHMENT ,
NO.OF BLDGS. PERMIT O.
LICENSED CONTRACTORS DECLARATION e
SIZE NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter usE
9 (commencing with Section 7000) of, Division 3 Of the Busi- CHARGES
ness and Professions Code, and my license is in full force an
_ �_ CONNECTION CHARGE FEE
e ect. �j (��j �- CONTRACT
ns r Li .Class' ADDRESS IMBURSEMENT FEE >_
O OC
Date - ' DISTRICT NO. GROUP MAP PROCESSED BY �+
CIT TEL.N rr��
5 TE 04 LC. V BK PG, 0
lam exempt L ncl S of.t a L.A.Co. ucENs cLA
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORKFEE FINAL I0
HOUSE,SEWER.CONNECTING-TO DATE VALIDATI RI
�
B. 8 P. Code for the followinPUBLIC SEWER,'g reason 6s9
SEPTIC TANK,SEEPAGE PIT OR JIL
PITS AND/OR DRAINFIELD FINAL N
Date HOUSE.SEWER CONNECTING TO BY
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 ;2 1 5 2 O A
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM o ° ° a 1 O
❑ I,as owner of the'property,or my employees with wages as ri
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business •° ° 2 7,50
and Professions Code). OWNERS Permit . $
❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE ° ° 0 2 7 5 O
licensed contractors to construct the project (Section 7044, , I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED�CT.11
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. O G r� 13-85 3_8 5
CONSTRUCTION LENDING AGENCY. 1
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
issued (Sec. 3097, Civ. C.).
ADDRESS '
Lender's Name -
Lender's Address
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 Plumb''g and Sewers,
nd hereby authorize representotiv s of thi County to enter
n above-mention pro rt for ins ection p rpases.
C ��
Signatur of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE