HomeMy Public PortalAbout6275 IVAR AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm. that I-have a cehificaW of. consent to self
-insure, or a certificate of Workers'Compenso'Mon.In'sur3nce, or 76A642D
a certified copy thereof (Sec. 38W,,Lcib C. 92-0002 DPW 6/88
Policy No.—Co mp66y
❑ Certified copy is hereby furnished.. - SIEWEIR 7 .SEWAGE DOSp®SAL
❑,Certified copy is filed witK the county building inspection COUNTY OF LOS ANGELES BUILDING ANDSAFETY
department. u
Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING / STATION DEPTH
COMPENSATION INSURANCE ADDRESS 62, , ZUPES
(This section need not be completed if the work involved by theLOCALITY f CA MANHOLE REFERENCE OWER
UPPER
permit is for one hundred dollars ($100)or less.)
I certify that in the performance of the work V. CURB P.I. M.L.TO P.L:rk for .which this NEARESST. TYPE OF CONNECTION LENGTH FROM
permit is issued, I shall not employ any person in any manrier P.C.NO.
so as to become subject to the Workers'Co ensation Laws. OWNER , �' -Tu
��j CO.IMP.NO. JOB NO.
te_ �pplicant ADDRESS -YY YU (yiMAIL TRUNK PERMIT NO. ROAD PERMIT NO.
NOTICE TO APPLICANT: If, after making this rtificate Of CITY M U I TEL.NO. AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
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 0 - STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO.SIZE of Lor 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 Busi- BUILDINGS CHARGES
ness and Professions Code, and my license is in full force and
effect. CONTRACTOR CONNECTION CHARGE FEE
License Number - Llc.Class ADDRESS REIMBURSEMENT FEE -
Contractor Date DISTRI O. GROUP MAP P OCESSED BY
. _ CITY TEL.NO. � ^ BK PG �..
v CL
❑ I am exempt under Sec. _of the L.A.Co. LICENSE NO. CLASS O
()
Plumbing Code and/Or Sec. of the - NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO DA EL D TION
B. & P. Code for the following reason PUBLIC SEWERSEPTIC TANK,SEEPAGE PIT ORO
PITS.AND/OR DRAINFIELD FINAL - 1-
Date HOUSE,SEWER CONNECTING TO . BY U
liJ
PRIVATE DISPOSAL SYSTEM A a
Signature - CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION 'WORK TO HOUSE SEWER _z
ERFLOW SEEPAGE PIT,DRAINFIELD
I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE 3307 I7 c 1
Law for the following reason (Secton 7031.5, Buisness and Pro- j ALTER,REPAIR OR•ABANDON HOUSE' 61.
fessions Code): SEWER OR DISPOSAL SYSTEM VOID
❑ I,as owner of the property,or my employees with wages as �`tL.Ii� ,ru
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permit $
❑ 1,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE A �`1
licensed contractors to construct the project Section 7044, 0- 9.I
P I ( I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CO A TO O �� f o .}.t
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PU SEWER.
CONSTRUCTION LENDING AGENCY i ITE
I hereby affirm that there is.a construction lending agency SIGNED THIS DAYOF 19_ T
for the performance of the work for which this permit is OWNER OR 1 j TTL 27 m 00
OWNERS AGENT
issued (Sec. 3097, Civ. C.). CHECK
ADDRESS CHECK
Lender's Name
CHANGE o ESI j
Lender's Address
certify that I have read this application and state that the
above information is correct. I agree to comply with all County CI ►Ot�-C10�1 !� fl%`cif
ordinances and State laws regulating Plumbing and Sewers, i Ct"e(3'i
and hereby authorize representatives of this County to enter gj_18 y €M
Upon the DID mentioned property for inspection purposes.
Signature of Permit Date SEE REVERSE FOR EXPLANATORY LANGUAGE