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HomeMy Public PortalAbout4919 KAUFFMAN AVE_Mechanical__ WORKERS4 COMPENSATION DECLARATION I ereb• affirm that I have a certificate of consent to self 92-0002 DPW 3/87 .r 76A642D ' insure, or a certificate of-Workers'Compensation Insurance, or cEeDe t—certifiedC. Cher o�yf.(2 3800, Lab C. Qpp�p�QTpOO �] FOR pEQ�O� Policy No. Coraryyy $ Os SEWERER " J2ppAGE DOSnOSQL❑ Certified copy Is hereby furnished. Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Date Applicant r ou ' FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTIOD FROM WORKE BUILDING �c. COMPENSATION INSURANCE ADDREss ,t��/Q STATION DEPTH (This section need not be completed if the work involved by the ,D /' MANHOLE REFERENCE f � PER permit is for one hundred dollars ($100)or less.) LOCALITY l C/ LOWER NEAREST + !' (� TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS SL J7 1J'N 9- �OW IC �� Y. CURB P.L. M.L.TO P.L. permit is issued, I shall not employ any person in any manner jL, ( J so as to become subject to the Workers'Compensation Laws. OWNER /1 �f I I G�'7 P.C.NO. CO.IMP.NO. JOB NO. MAILAFFIDAVIT i ]• v ©L JI! TRUNK PERMIT NO. ROAD PERMIT NO. WAIVER EASEMENT RECORD.INSTR.NO. DATE 'ADDRESS PQ Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of 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 f� revoked. BLOCK TRACT J OP STATE ENCROACHMENT �/ No.OF BLDGS. PERMIT NO. LICENSED CONTRACTORS DECLARATION SIZE OF LOT 5 /� ` NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter USE of 'j 9 (commencing with Section 7000) of Division 3 of the Busi- BUILOINGS L f •Q i CHARGES ness and Professions Code, and my license is in full force and n'/ y effect. - CONTRACTOR 1 1'^4 i" CONNECTION CHARGE FEE - License Number Y � � IC.Class V REIMBURSEMENT FEE a. ADDRESS rZ U.2. .e d �� DISTRICT NO. GROUP MAP PROCESSED BY 0 Contractor A Date 2 CITY n TEL.NO. 1 114-1' E; T vv ` U BK PG Z /- -7 ❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. 6� v C ASS@ 0 NO: DESCRIPTION OF WORK' - FEE U Plumbing Code and/or Sec: of the FINAL HOUSE SEWER CONNECTING TO DATEI VALIDATION LU B. 8 P. Code for the following reason PUBLIC SEWER 1 SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO - BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.ORO D OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER a 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 (Secton 7031.5,,Buisnes5 and Pro- ALTER,REPAIR OR ABANDON HOUSE i ! fessions Code): SEWER OR DISPOSAL SYSTEM ❑ I,as owner of the property,or my employees with wages ast-;-'• °' their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business 3' r3 and Professions Code). OWNER'S I Permit $1 1510,6 ❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION 1 TOTAL FEE �f B� licensed contractors to construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO = Y,L- f m 5-?�D Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. HF­CONSTRUCTION LENDING AGENCY SIGNED THIS DAY OF I PI� 19_/� � K / I hereby affirm that there is a construction lending agency OWNER OR ,D CHANNGE XI! for the performance of the work for which this permit is OWNERS AGENT - issued (Sec. 3097, Civ. C.). -� ' ADDRESS 0 2 Lender's Name ' ,!.li1_i` Lender's Address s j�,._ I certify that I have read this application and state that the J= _ 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 P "ittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE