HomeMy Public PortalAbout6133 IVAR AVE_Sewer__ WORKERS'COMPENSATION DECLARATION CE 808 (D2-80) APPLICATION F®R PERMIT
I hereby affirm that I have a certificate of consent to self SEWER—SEW GE DISPOSAL
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab. C.) COUNTY OF LOS ANGELE'S r BUILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN CONNECTION DATA
BUILDING /� �+ ��+ STATION jDE-PTH
XCertified copy is filed with the county building inspection ADDRESS Low y t . UPP
depa me MANHOLE REFERENCE
/p LOCALITY �mZ-`J/L� �� r 7 LOWER-
Dat '� � Applicant ��k-�s!/ ` "Y'������. NEARESTTV PE OF N TION LENGTH R
RT ATE OF EXEMPTION FROM WORKERS' CROSS ST. Y. CURB P.L. M.L. T L.
K
COMPENSATION INSURANCE owNER � - 20 P.C. NO.
CO. IMP. NO. ` J JOB NO.
MAIL _
(This section need not be completed if the work involved ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO.� a
by the permit is for.one hundred dollars ($QQ100) or less.) AFFIDAVIT WAVER EASEMENT RECORD. INSTR.NO. DATE O
CITY TEL. NO. V
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. ccNWY. OR ST. WIDENING O-
so as to become subject to the Workers' Compensation Laws. 0
l I ��f z BLOCK TRACT STATE ENCROACHMENT U
Date= �✓pplicant l>e G- J N�/7"� -�/VNO. OF BLDGS. PERMIT NO. f/IJ� a
NOTI E T APPLICANT: If, after making this Certificate of slzE of Lor Now ON Lor � � �`
Exemption, you should become subject to the Workers' USE OF
BUILDINGS CHARGE'9_
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be �..,t CONNECTION CHARGE FEE
deemed revoked. CONTRACTOR
LICENSED CONTRACTORS DECLARATION. ADDRESS �, �X / t�. REIMBURSEMENT FEE
I hereby affirm that I am licensed under provisions of Chapter
CITY { �.�yy r o1sTRlcr NO. GROUP MAP P oc SED BY
'ir�,/q� D7� TEL. NO. ', BK PG
9 (commencing with Section 7000) of Division 3 of the Busi- �jSTATE j
ness and Professions Code, and my license is in full force and LICENSE No. CLASS
4'�fJ
effect. NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO ``�� FINAL / VALIDATION
License Number' 3"� '' Lic:Class �- ��— PUBLIC SEWER �L✓ DATE
r / SEPTIC TANK,SEEPAGE PIT OR
Contractor �+oe G 6114ea Date - �/ PITS ANO/OR GRAINFIELD FINAL
HOUSE SEWER CONNECTING TO
' 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 In my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT,DRAINFIELD
iness and Professions Code). EXTN.,CESSPOOL,DRYWELL,MANHOLE'
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION ')
I hereby affirm that I am exempt from the Contractor's OWNERS Permit S �a
License Law for the following reason (Section 7031_.5, Busi- AUTHORIZATION TOTAL FEE t
ness and Professions Code):
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
O - �YRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING '
I, as owner of the property, will do the work and the TO THE PUBLIC SEWER.
����jjrr �9 / Z 4 3 5,5 A
structure is not intended or offered for sale (Section SIGNED THIS� DAY OF®%�"/f�F 19 �
7044, Business and Professions Code). OWNER OR .
OWNERS AGENT #-0,0 O O 11 O
CONSTRUCTION LENDING AGENCY ' ADDRESS
I hereby affirm that there is a construction lending agency 2.0 o.1 00
for the performance of the work for which this permit is
issued (Sec. 3097,Civ.C.). :o 0 0 1 8 0 0J
Lender's Name
03, 11 -81
Lender's Address
I certify that Ty-e--read [ s application and state that the
above info ation is corr . I agree to comply with all County
ordina and Stat aws gulating P ing and Sewers,
and i reb au presentati f this County to enter
u o o enti prop for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Permittee Date