HomeMy Public PortalAbout6251 IVAR AVE_Sewer__ WORKERS' COMPENSATION DECLARATION �j
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hereby'affirm.that I have a certificate of consent to self 20DD5T DPW 6/89 ��JJ
insure,'or'a certificate of Workers' Compensation Insurance, or 76A642D
a certified copy�t#hereof"(Sec. 3800, Lab C.) , • /pl��(� ������(�(� �Oa
PolicyiVo. -V63 Company r��fw_ r A pLspe A q N ISo�1ovU
5C Certified copy is hereby furnished. SEWER a SEWAGE DISPOSAL
❑ Certified copy is filed with the county building inspection t - COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Dote/2-7—1i Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING �j
COMPENSATION INSURANCE ADDRESS STATIONS r9S DEPTH
(This section need not be completed if the work involved by the ����� �jTti MANHOLE REFERENCE ?i 3 -9SJl UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY / LOWER
NEARESToA q TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this caoss ST. K/ v CURB P L M L TO P L
permit is issued, I shall not employ any person in any manner LEGAL
PC NO
so as to become subject to 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 making this Certificate Of ASSESSOR Q/ {� AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
g MAP BOOK Q to PAGE G/�O PARCEL��
Exemption, you should' become 'subject to the Workers' NO.OFBLDGS.
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 �/ 10/0-S
9 (commencing with Section 7000) of Division 3 of the Busi- MAIL
ADDRESS /l CHARGES
Hess and Professions Code, and my,license is in full force and �
effect. CITY TEL.NO. 39901 -�LO CONNECTION CHARGE FEE
License Number Lic.Class CONTRACTOR REIMBURSEMENT FEE
/ Y/E'�`Y�/� w� !,�
Contracto��'_1rW-y Date /Z— ADDRESS /0_:W!- 6AV 6X-14P*W'^.0 DISTRICT NO GROUP BK MAP PG PROCESSED BY
❑ 1 am exempt under Sec. of the L.A.Co. )�)L � r � D n}.
CITY L`A14 TEL.NO. bJ/f '� �✓ /// ` ��� Q
Plumbing Code and/or Sec. of rhe STATE 2 f� ¢ LIC. 12 TINA'
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LICENSE NO. c7 CLASS 10I DATE ., � I&LIDATION z
B. 8 P. Code for the following reason NO. 1 DESCRIPTION OF WORK FEE 1 g0
HOUSE SEWER CONNECTING TO / FINAL ACCT.s !--
Date PUBLIC SEWER (p BV �.1.}V•y♦♦i�((''��7.} 73-1SEPTIC TANK SEEPAGE PIT OR
PITS AND OR DRAINFIELD
Signature D HOUSE SEWER CONNECTING TO I
i ITEMS Z
OWNER-BUILDER DECLARATION
PRIVATE DISPOSAL SYSTEM _
I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR TOTAL 73 o 50
Law for the following reason (Secton 7031.5, Buisness and Pro- WORK To HOUSE SEWER CHECK
fessiOnS Code): INFIELD
EOVERFLOW TNC CESSPOOL.DRVW LL.MANHOLE CHECK 73.50
❑ 1, as owner of the property, or my employees with wages Os ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM CHANCE .00
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business
and Professions Code). n Fy i a
El 1, as owner of the property, am exclusively contracting with 0000-MOI 1?/ 7/95
licensed contractors to construct the project (Section 7044, OWNERS Permit $ �' 6 3643 1 AM 10=17
Business and Professions Code). AUTHORIZATION TOTAL FEE Q
CONSTRUCTION LENDING AGENCY I HAVE T THIS DATE A CONTRACT WITH THE HEREIN NAMED C NTRACTOR TO
AD
I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER
for the performance of the work for which this permit is ��LL
issued (Sec. 3097, Civ. C.). SIGNED THIS 7 DAY OF19y`r
OWNER OR
Lender's Name OWNERSAGENT
ADDRESS
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 property for inspection purposes.
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE