HomeMy Public PortalAbout5042 KAUFFMAN AVE_Sewer__ WORKERS'COMPENSATION DECLARATION CE 808 ( APPLICATION
s ®fes p I C AT OO 1 FOR
PERMIT-
I
76 808 (280) f"l Ir Ir I� �I
I he Aeby affirm that I have a certificate of consent to self SEWER—SEW
E DISPOSAL
insure, or a certificate of Workers Compens on In^ ra ice or
a certified copy thereof(Sec. 3800,Lab.C COUNTY OF LOS ANG E ES BUILDING AND SAFETY
Pol' pan
Eifie p Is eK reby rnished. �/� FOR APPLICANT TO FILL IN CONNECTION DATA
BUILDING .Iry / STATION DEPTH
Certified copy is filed with theAunty b i di 1 ection ADDRESS ((�� UPPER
d art �� MANHOLE REFERENCE
.j LOCALITY e/(yt.... L LOWER
Date Appllca it NEAREST `c TYPE OF CONNECTION LENGTH FROM
CERTIFICATE OF EX EM TION FROM WORKERS' cRoss sr. �' /W t�� Y. CURB P.L. M.L. TO P.L.
COMPENSATION INSURANCE P.C. NO.
OWNER CO. IMP. NO. JOB NO.
M AIL
^
(This section need not be completed if the work involved ADDRESS L TRUNK PERMIT NO. ROAD PERMIT NO. O
by the permit is for one hundred dollars ($100) or less.). c < U
AFFIDAVIT WAIVER EASEMENT REC ORO. INSTR.NO. DATE
` CITY �`/�— NO.� � �
I certify that in the performance of the work for which this LEGAL 0
permit is issued, I shall not employ any person in any manner DESCRIPTION Lor NO. HWY. OR ST. WIDENING
so as to become subject to the Workers' Compensation Laws. U
BLOCK TRACT STATE ENCROACHMENT W
Date Applicant NO. OF BLDGS. PERMIT NO. Q.
SIZE OF LOT NOW ON LOT to
NOTICE TO APPLICANT: If, after making this Certificate of Z
Exemption, you should become subject to the Workers' USE OF CHARGES
Compensation provisions of the Labor Code, you must forth- BUILDINGS
with comply with such provisions or this permit shall be CONNECTION CHARGE FEE
deemed revoked.
CONTRACTOR `i(,
REIMBURSEMENT FEE
LICENSED CONTRACTORS DECLARATION ADDRESS
I hereby affirm that I am licensed under provisions of Chapter DISTRICT NO. GROUP MAP P E ED BY
9 (commencing with Section 7000) of Division 3 of the BusiSTAT Z- clTv L. No. Cgr
ness and Professions Code, and my license is in full force and
LICENO. 7� CLASS (�
k
effect. / NO. 1 DESCRIPTION OF WORK, FEE
HOUSE SEWER CONNECTING TO FINAL a VALIDATION
License Numbe ` °° Lic.Class PUBLIC SEWER DATE re �
/��7/ ��l//J�I/g�,,,/�)J �/{}�/� 7 ��,�.i%��. SEPTIC TANK, SEEPAGE PIT OR
Contractor ✓1��� /j /1 �� e LJ PITS AND/OR DRA INFIELD
Date FINAL
HOUSE SEWER CONNECTING TO BY
O ,
I am exempt from the licensing requirements as I am a PRIVATE DISPOSAL SYSTEM
ONNECT ADDITIONAL BLDG.OR
licensed architect or a registered professional engineer WORK TO HOUSE SEWER
acting In my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT,DRAINFIELD `=%=6%%y (i%'+XV✓
iness and Professions Code). EXTN.,CESSPOOL,DRYWELL, MANHOLE '
ALTER, REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM u
Lie.or Reg.No. Date /
HOME OWNER-BUILDER DECLARATION
77
I hereby affirm that I am exempt from the Contractor's OWNERS Permit S
License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE
ness and Professions Code):
1 HAVE AT THISDATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
ElI, as owner of the property, will do tfie work and the TO THE PUBLIC SEWS/$ly,
structure is not intended or offered for sale Section T 21 4;1 A
( SIGNED THIS i DAY OF
7044, Business and Professions Code). OWNER OR # o oto 0.1
OWNERS AGENT { , O
CONSTRUCTION LENDING AGENCY gDDRE55 / D O
I hereby affirm that there is a construction lending agency 2. 1 4;0.0
for the performance of the work for which this permit is
issued (Sec. 3097,Civ.C.). ;o,0 0 14005
Lender's Name
09 '1 "5•-80'
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 herpby authorize representatives of this County to enter
upon t e above-mentiioonnedd ' y for inspection purposes.
l/'f J� �„ � SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Permittee Date