HomeMy Public PortalAbout5039 HELEO AVE_Sewer__ �,bylffl,�
KERS'COMPENSATION DECLARATION
that I have acertificate of consent to selfin , ificate of Womkers'Compensation Insurance, or 7eAmzD
a certified copy thereof (Sec. 3800,10C. CE 808(REV.6B APPLICATION FOR PERMIT
Policy No. Company 4 « Os
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
Certified copy is filed with t aunty b ildin inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
departm.�en_t.
Dote �• Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WOR BUILDING
COMPENSATION INSURANCE ADDRESS STATION DEPTH
(This section need not be completed if the work involved by the LOCALITY MANHOLE REFERENCE UPPER
OWER
permit is for one hundred dollars ($100)Or 1e55.) NEAREST L a " Y TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CR SL J•^-' CURB PA TYPE
M.L.TO P.L.
permit is issued, I shall not employ any person in any manner P.C.No.
so as to become subject to the Workers'Compensation Laws. OWNER L et Ld r ell co i5 r •(j CO.IMP.NO. JOB NO.
MALI
Date Applicant ADDRESS TRUNK PERMIT NO, ROAD PERMIT NO.
e
NOTICE TO APPLICANT: If, after makin this Certificate O{ AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
g CITY TEL.NO.
'Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR Si.WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO. ON LOT OF BLDGS. tJ PERMIT NO
SIZE OF LOT NOW ,
F-
Ihereby affirm that I am licensed under provisions of Chapter bE OF ]]'�'�
9 (commencing with Section 7000) of Division 3 of the Busi- LEI 5,F,D • CHARGES
ness and Professions Code, and my license is in full force and
effect. CONTRACTOR •/( IP L0 CONNECTION CHARGE FEE 1
License Numbe 0703 Li<. Class ADDRESS ���J�I �( REIMBURSEMENT FEE Q
/t� ���� DISTRICT NO. GROUP MAP PROCESSED BY
ClOr
COntrO ,Le�ate • /L�(l / CITY •TEL. O 246Q_ V /\,,T/ BK PG O
❑ 1 am exempt under Sec. of the L.A.Co. LICENSE NO. O CLASS Ur/ �-' 0
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL VALIDATI N d
HOUSE SEWER CONNECTING i0 DATE
a
B. 8 P. Code for the following reason PUBLIC SERVER
SEPTIC TANK,SEEPAGE PIT OR N
PITS AND/OR DRAINFIELD FINAL
Date HOUSE SEWER CONNECTING i0 BY
�� �,�--• PRIVATE DISPOSAL SYSTEM -
$iaaatme2ya ���\—� CONNECT ADDITIONAL BLDG.OR I /1 )
OWNER-BUILD D A ION WORK TO HOUSE SEWER L1
I herebyaffirm that I am exe Contractors License OVERFLOW CES SEEPAGE PCL.ELL,MANN
P E%iN.,CESSPOOL, BAND I.MANHOLE pool
0 33117 G
Law for the following reason ($e<tOn 7031.5, BUlsn¢5$and PFO- ALTER.REPAIR OR A SYST M.HWSE t rH
{essions Code): SEWER OR DISPOSAL SYSTEM 1 1T_t r,_
❑ 1,as owner of the property,or my employees with wages as UTAL .92 m cC
their sole compensation, will do the work and the structure - Yi.cll
is not intended or Offered for sole (Section 7044, Business CHECK
and Professions Cade). OWNERS Permit $ IQ
❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE5 Lj CHANGE ,CILI
licensed contractors to construct the project (Section 7044, 1 1
HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRA TOR TO
Business and Professions Code I HAVE
THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. nl Il~-0I I /12!89
CONSTRUCTION LENDING AGENCY � ll 1111 1,
1 hereb affirm that there is a construction lending agency SIGNED THIS DAY Of I9_ C. O j; 9
Y 9 9 Y OWNER OR poll i]3:t 1 Atilt �.
for the performance of the work for which this permit is OWNERS AGENT
issued ($e<. 3097, Civ. C.).
ADDRESS
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, `
an authorize representatives of this County to enter ,I
pan I Ove- an n�d property for inspection purposes.
iJiZ _
Signature o Permit a Date SEE REVERSE FOR EXPLANATORY LANGUAGE