HomeMy Public PortalAbout6031 IVAR AVE_Sewer__ WORKERS' COMPENSATION DECLARATION
I hpj 'bi# affirm that I have a certificate of consent to self 20-0051 DPW 6/89 ,r.,�. s'►
insure, or}a certificate of Workers' Compensation Insurance, or 76A642D K �"
P J ,e ��aS��7�0 Compthereof any.
SEWER
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❑ Certi�d'c6p�s hereby furnished / e/ �LStlC/LS� �ISVG��LS ®���®���
[A'C'ertified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
depart m nt
Date 95 Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING , III STATIONDEPTH
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COMPENSATION INSURANCE ADORES
(This section need not be completed if the work involved by the MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100) or less.) LOCALITY LOWER
NEAREST ,// TYPE OF CONNECTION .}.rr LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. HGkow5 Y CURB P i 3 ML TOP L
permit is issued, I shall not employ any,person in any manner LEGAL
PC NO
50 OS 10 become Subject 10 the Workers' Compensation Laws. DESCRIPTION LOT NO. CO IMP NO JOB NO
BLOCK TRACT TRUNK PERMIT NO - ROAD PERMIT NO
Date Applicant
NOTICE TO APPLICANT: If, after makingthis Certificate Of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
MAP BOOK PAGE PARCEL
Exemption, you should become subject to the Workers' NO.OF BLDGS.
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:OF
revoked. BUILDINGS STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION PERMIT No
I hereby affirm that I am licensed under provisions of Chapter
OWNER
9 (commencing with Section 7000) of Division 3 of the Busi- MAIL CHARGES N ,1„va< aA,ry,�
l�`
Hess and Professions Code, and my ADDRESS n license is in full force and Q /
effect. _ CITY 1" - TEL.NO. ��Q b S�t CONNECTION CHARGE FEE
License Nu er �� ��74Lic.Class j��-,� REIMBURSEMENT FEE
//,,�y CONTRACTOR R� �lJ��..
Contrac �J D®•iE"U DISTRICT NO GROUP MAP PROCESSED BY
ADDRESS 9( �p c<" BK PG
El am exempt under Sec. of the L.A.Co. TEL.NO. � Q
CITY � d
Plumbing Code and/or Sec, of the STATELIC. FINAL U
LICENSE NO. 3 5-31-70 CLASS DATE L VALIDATION Z
B. & P. Code for the following reason , NO. DESCRIPTION OF WORK FEE � i� O
AL
n / /� HOUSE SEWER CONNECTING TO FINF-
Date
PUBLIC SEWER BY W
it SEPTIC TANK SEEPAGE PIT OR - d.
L--Signature PITS AND OR DRAINFIELD
OWNER-BUILDER DECLARATION HOUSE SEWER E
PRIVATE DISPOSSALAL SYSTEM -
I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR.
Low for the following reason (Secton 7031.5, Buisness and Pro- WORK TO HOUSE SEWER
fessions Code): OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN CESSPOOL DRYWELL.MANHOLE /'/'�
El 1, as owner of the property, or my employees with wages Os- ALTER,REPAIR OR ABANDON HOUSE jry ACC i T
a'8'
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their sole compensation, will do the work and the structure SEWER OR DISPOSAL SYSTEM 3303 57=20
is not intended or offered for sale (Section 7044, Business
and Professions Code). I ITEMS
❑ I, as owner of the property, am exclusively contracting with OWNER'S Permit $ � Q TOTAL _�_a a
licensed contractors to construct the project (Section 7044,
20
Business and Professions Code). AUTHORIZATION FTOTAL FEE d CHECK 57.20
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER C.�� .00
for the performance of the work for which this permit is
issued (Sec. 3097, Civ. C.). SIGNED THIS DAY OF lv_ (.}�{{���•}}�({ �{�
OWNER A 0000 0001 12/28/x9~
Lender's Name OWNERS AGENT
Lender's Address ADDRESS 0590 L PM 6:20
1 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 above-mentioned property for inspection purposes.
gnatur Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE