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Home My Public Portal About9823 HOWLAND DR_Sewer__ WORKERS' COMPENSATION DECLARATION [� I hereby,offirm that I hove o certificate of consent to self 200051 DPW 6189 U •insure, or a certificate of Workers'Compensation Insurance, or 76A642D a cert°Ted copy thereof 3800. Lab` ' APPLICATION FOR PERMIT Policy No. camom pa ny ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Dote Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING p OO'' / COMPENSATION INSURANCE ADDRESS / e.p L�uO srnnON �...&�� O DEPTH (This section need not be completed if the work Involved by the LOCALITMANHOLE REFERENCE �O � PP permit is for one hundred dollars ($100)or less.) NEAREST eR I certifythat in the performance of the work for which this NEAREST TYPE OF CONNECTION LENGTH LOPL P CROSS ST. v CURB P L M l LOPL L permit is Iswed, 1 shall not employ any person in any manner LEGAL PC NO Sa as la became Subject to the Workers' Compensation Laws, DESCRIPTION LOT NO. CO IMP NO JOB NO q BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO 1/Date_9 `Appfcant� ASSESSOR AFFIDAVIT I WAIVER EASEMENT RECORp INSTR NO DATE NOTICE TO APPLICANT'. If, after making ibis Certificate of MAPBOOK PAGE PARCEL Exemption, you should become subject to the Workers' NO.DE Blocs. Compensation provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT HWY OR ST WIDENING comply with such provisions or this permit shall be deemed USE DE revoked. BUILDINGS STATE ENCROACRMENT LICENSED CONTRACTORS DECLARATION PERMIT NO I hereby affirm that I am licensed under provisions of Chapter OWNER G 9 (commencing with Section 7000) of Division 3 of the BmU MAIL —p�3% N^Q ness and Professions Code, and ri license is in full force and ADDRESS O •7 '[ CHARGES effec 1. CITY L�/�[ TEL NO. �C�J �� CONNECTION CHARGE FEE License Number 15124; Z Lic.Class CJ-' �FJ REIMBURSEMENT FEE PiM ti �/ 9 p CONTRACTORIII ✓ -�.v! COahpTtOr� r-'IJv. Dote //�G—/ Z /qJ �, ',/ DISTRICT NO GROUP MPP P ROCESSED BY ADDRESSS12 v✓. M11 ❑ lam B-emptunde1SeC. OfineL.A. CO. CITY�j TEL.No. 6—ZZ � 5 �!o Plumbing Code and/or Sec. of the STATE LIG FINAL - U d,' //max �}� LICENSE NO, -5'©62199 CLASS G`,3� DATE VALIDATION Z 8. & P. Code for the fallowing rea5orL70& '�V v HR' NO. DESCRIPTION OF WORK FEE Dare / -IG-9 L HUOeuc sewie coNNEa TNG TO NAL U SEPTIC TANK SEEPAGE PIT OR W a Signature PITS AND OR D4AINFIf ID N OWN R-BUILDER DECLARATION HOUSE SEWER CONNECTING TO -. , Z PRIVATE DISPOSAL SYSTEM I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BIDS OR Law for the following reason (Sectors 7031.5, Buisness and Pro- WORK TO HOUSE SEWER 'IJ fE551On5 Code): OVERFLOW SEEPAGE PIT DRAINFIELO EXTN CESSPOOL DRYWELI MANHOLE = ❑ 1,a5 Owner of the property, Or my employees with wages as ALTER REPAIR OR ABANDON HOUSE ACCT. •14 SEWER OR DISPOSAL Sv51EM their sole compensation, will do the work and the structure 3?07 66.3 is not intended or offered for sale (Section 7044, Businessand Professions Code). '{ 1 ITEMS ❑ I, as owner Of the property, am exclusively Contracting with permit s TOTAL 66 - 53 licensed contractors to construct the project (Section 7044, OWNER'S Business and Professions Code). AUTHORIZATION TOTAL FEE r;(-(ECK E(y, CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED COMPACTOR 10- C ANNE -f hereby affirm that There is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER [J for the performance of the work for which this permit Is L, issued (Sec. 3097, Civ. C SIGNED THIS DAY OF 19OWNER _. Leaders Name OWNERSOAGFNT ;� QI�I.11 -1��1�1 9/16!92 Lender's Address ADDRESS @, .. 54 �_ 1 AM -t:45 I certify Iho1 I have read this application and stale that the above InformmlOn IS correct. I agree to comply with all County - E ordinances and Slate lows regulating Plumbing and Sewers, and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE l