HomeMy Public PortalAbout6142 IVAR AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or i6A642D
a certified copy thereof (Sec. 3800, Lab C.) CE 808(REV.1/83) /p�PPLO([ /O�U00H FOP, nlSRMOU �I
Policy No. Company U'U cel❑1V/rU I7 V c��+ (I (���
❑ Certified 'copy is hereby furnished. SEWER a SEWAGE DOSPOSAL
❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Date Applicant FOR APPLICANT TO FILL IN / CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION /_ G 3 DEPTH
f.
COMPENSATION INSURANCE ADDRESS so
(This section need not be completed if the work involved by the MANHOLE REFERENCE J7 1`
OLE ,z Z �' -/'fes
Perm it is for one hundred dollars ($100)or less.) LOCALITY
I certifythat in the performance of the work for which this 1 NEAREST TYPE OF CONNECTION LENGTH FROM
p CROSS ST. Y. CURB P.L. M.L.TO P.L.
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation LOWS. OWNER CO.IMP.NO. JOB NO:
, MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
at�7�Applicant >' 4m ADDRESS
NOTICE TO APPLICANT: If, ter makingtl�ifi�of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
. 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 ST WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT STATE ENCROACHMENT
N
LICENSED CONTRACTORS DECLARATION OF PERM1 No,
DD
I hereby affirm that I am licensed under provisions of Chapter USE OF SIZE OF LOT NOW OT
W ON LOT '
9 (commencing with Section 7000) of Division'3 Of the Busi- BUILDINGS CHARGES
ness and Professions Code, and my license is in full force and
effect CONTRACTOR. CONNECTION CHARGE FEE
License Number LIc'.Class ADDRESS REIMBURSEMENT FEE
Contractor DateCITY TEL.N0. DISTRICT NO. GROUP MAP PROCESSED I3Y
BK PG
STATE LIC. s
O I am exempt under Sec. of the L.A.Co. LICENSE NO. CLASS
NO. DESCRI ION OF WORK FEE So�' f-3 O
b
Plumbing Code and/or Sec. of the FINAL ' VALIDATION M
'HOUSE SEWER CONNECTING TO DATE .. ��
B. & P. Code for the following reason PUBLIC SEWER
SEPTIC TANK,SEEPAGE PIT OR H
PITS AND/OR DRAINFIELD FINAL f •�
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM t
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 o /1
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE ().1 O'[}/ A
fesslons Code): SEWER OR DISPOSAL SYSTEM a o'o o Q
❑ I,as ovwner of the property,or my employees with wages os
their sole compensation, will do the work and the structure
is not'intended or offered for sole (Section 7044, Business permit g L1 210 ro 217.'5 0
and Professions Code). OWNER'S
❑-I, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE 0-71 2 7.�5 0'65
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. - 0222-84
CONSTRUCTION LENDING AGENCY
I 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 oa
issued (Seca 3097,Civ. C.). OWNERS AGENT
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,
and hereby, authorize representatives of this County to enter
Upon the above-mentioned nproperty for inspection purposes.
4SnOtue of Permit a Dote SEE REVERSE FOR EXPLANATORY LANGUAGE