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HomeMy Public PortalAbout6262 IVAR AVE_Sewer__ 4S'COMPENSATION DECLARATION z DPW s/B7 9z-000 that I have a certificate of consent to self 92-00076A642D certificate of Workers'Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab C., ' ce 808 ., /n�I�f�fl �C /�1�f'� O f�f1 2 • R ���n(��5� Polic� No. ' Company ©s lf"P G �1 ll Oppm FOR 9�/u Il ❑Certified Copy is hereby furnished. SEWER•e '�E AOE 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' BUILDINGSTATION DEPTH COMPENSATION INSURANCE ADDRESS fJ C� V. (This section need not be completed if The work involved by the \ MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) LocnurY �7y1/'L( LOWER ' I certify that in the performance of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROMCROSS ST. /V Y. CURB P.I. M.L.TO P:L. permit is issued,-1 shall not employ, any person in any manner P.C.NO, s0 a5 10 become subject to t&eo, WsCpen safion Laws.. OWNER � � } fZl �[:L,1Q/1 CO.IMP.NO. .JOB NO. MAILDate_I��__ PPIicanDDRESSQ) TRUNK PERMIT NO. ROAD PERMIT NO. NOTICE TO APPLICANT:.If, after making this Certificate of c1Tv. / AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE {�tl - TEL.NO. Exemption, you should become subject to the Workers' 72 7 LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING, t•' " comply with such provisions or this permit shall be deemed ^ t revoked.. BLOCK _ TRACT V' STATE ENCROACHMENT"- LICENSED CONTRACTORS DECLARATIONSIZE OF LOT t� loo NO.OF BLDGS. PERMIT NO.NOW ON LOT ' I hereby affirm that I am licensed under provisions of Chapter USE OF 9 (commencing, with Section 7000) of Division 3 of the BUST- BUILDINGS' CHARGES ness and Professions'Code, and:my-license is in full force and effect. - CONNECTION CHARGE FEE CONTRACTOR - �G!//�Lam' , License Number LIG.Class ADDRESS REIMBURSEMENT FEE 0 Contractor- Date ' DISTRICT No. GROUP -.MAP PROCESSED BY U CITY TEL;No. ' _ /� gK PG ❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. CLASSY R m 0 Plumbing Code and/or Sec. of the No. DESCRIPTION OF WORK FEE FINAL 0 ' HOUSE SEWER C NNECTIN TO '� 1 /�,If DATE,, VALID ION UJ B. & P. Code for the following reason Puguc.stwER U fl i L/ !( tit - SEPTIC,TANK,SEEPA PIT OR .01`1 (l? f;•ir ' - PITS AND/OR DRAINFIELD FINAL;�( Date HOUSE SEWER CONNECTING TO BY (U ' PRIVATE DISPOSAL SYSTEM } Signature - CONNECT ADDITIONAL BLDG.OR WORK TO HOUSE SEWER OWNER-BUILDER DECLARATION D 1_ OVERFLOW SEEPAGE PIT,DRAINFIELD 11-01* I hereby affirm that I am eXempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE �� fessions Code): SEWER.OR DISPOSAL SYSTEM - - z.9 2 9,6A ❑ I,as owner of the property,.or my employees with wages as their sole compensation, will do the work and the structure #:0 0 0 01 0 is not intended or offered for sale (Section 7044, Business and'Professions Code). OWNER'S Permit $ ( 0 0 2,7.5'0 ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION I TOTAL FEE licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO O-O O 2 7.5 0 5 Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. . 04,04i-88 CONSTRUCTION LENDING AGENCY D ' 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 OR OWNERS AGENT issued (Sec. 3097, Civ. C.). 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 ordin nces and State laws regulating Plumbing and Sewers, and reby aUthoriz r resentatives of this County to enter ft ove-me ion r erty for inspection purposes.of Perm tree Date SEE REVERSE FOR EXPLANATORY LANGUAGE