HomeMy Public PortalAbout4918 KAUFFMAN AVE_Sewer__ WORKERS'COMPENSATION DECLARATION '
I hereby affirm that I have a certificate of consent to self
insuw4or a certificate of Workers'Compensation Insurance, or 76A6421)
s eertified copy thereof,(Sec. 3800; Lai' CE s8 08(REV.8/81
- ) r ^l^ CATO M FOR
R PERMG
Policy No.-Company
�.
❑ Certified copy is hereby furnished. SEWER e SEWAIPE MSPOSAL
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 BUILDINGr r7 STATION DEPTH
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work involved by the MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY LOWER
I certifythat the performance of the Work for which this NEAREST _ TYPE OF CONNECTION LENGTH FROM
In e p CROSS ST. ,V. 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 Laws. P.C.NO.
I P OWNER d CO.IMP.NO. JOB NO.
MAIL '
Date Applicant ADDRESS TRUNK PERMIT NO. - ROAD PERMIT NO.
. s �,•- �.
NOTICE TO APPLICANT: 1f, after making Certificate Othis f CITY TEL.,NOAFFIDAVIT 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 V O D STATE ENCROACHMENT "
No.OF BLDGS. PERMIT No.
LICENSED CONTRACTORS DECLARATION
SIZE OF LOT 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 �A
effect. CONTRACTOR /�'�' CONNECTION CHARGE FEE
License Nu a Lic.Class `� G' ADDRESS � G( �C, l.T�)-x . REIMBURSEMENT FEE Q' 1
COniraCtor Dale �)?,C
/ DISTRICT NO. GROUP MAP PROCESSED BY V
CITY TEL:NO. / , B PG O
❑ I a e em t under Sec. of the L.A.Co. STATE UC. gr� ` ,{+�
P LICENSE NO. �. CLASS D I 4f? 5L��
F=
NO." DESCRIPTION OF WORK FEE" (�
Plu ng Code and/or Sec. of the FINAL NALIDAi ION
HOUSE SEWER CONNECTING TO DATE `•
PUBLIC SEWER - N
B. & P. Code for the following reason q
SEPTIC TANK,SEEPAGE PIT OR FINAL
PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING.TO BY
PRIVATE DISPOSAL SYSTEM
Signature CONNEWORK CT HOUSE SEAL BLDG.OR _
OWNER-BUILDER DECLARATION OVERFLOW SEEPAGE PIT,DRAINFIELD
I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE
Law for the following reason (Seclon 7031.5, Buisness and Pro- - ALTER,REPAIR OR ABANDON HOUSE 3.4'A fessions Code): SEWER OR DISPOSAL SYSTEM G 6 6.A 4 A -
❑ 1,as owner of the property,or my employees with wages as # 'o,0 0 0;l 0
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 $ ;J:9;° 211,5 0
❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION I. TOTAL FEE d2 S C
licensed contractors to construct the project Section 7044, o 0 0;2.�,5
P I ( I.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,
CONSTRUCTION'LENDING AGENCY D O a O 6`8 7
1 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
'issued (Sec. 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. Iogre to comply with all County
ordinances and State laws re gul t' g Plumbing and Sewers,
and h re authorize'represent ti es of this C unty to enter
upon a 3-megfioncd� ro er for inspec on p rposes.
ignaturePer to SEE REVERSE FOR EXPLANATORY LANGUAGE