HomeMy Public PortalAbout5202 KAUFFMAN AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that.I, have a certificate of cgnsentsto.`self
Insure,,or a certificate of Workers'CoropeAci ion 1n5urance, or 76A642D /•� I�I� ///777•/� M R Its}R�rp��/(��� G�I� -
a 5ertified`copy thereof(Sec.d3800, Lab C.) 92-0002 DPW 6/88 /p�PPLOCNTUDH F0 Ro PL7000Vu� ll
Policy No. 9Company 5Kd (T�1ll U (T1 -
❑ Certified copy is hereby furnished. �"���� �LS V V G�1,�� ®���®���
Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
/ department.
Datedd a• a' Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION F M WORKERS
COMPENSATION IN
RANGE ADDRESS ;LO oL + r m
UPPER
(This section need not be completed if the work involved by the LOCALITP G �� MANHOLE REFERENCE OWER
permit is for one hundred dollars ($100)or less.) NEAREST
1 certifythat in.the.. erformance of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROM
P. CROSS ST. S Y. CURB P.L. M.L.TO'PA.
permit-Js issued, I.sholPnot employ any person in any manner
so as to become subject.to the Workers:Compensation Laws OWNER r, P.B NO.
_ � fGb>}0`S CO.IMP.NO. JOB NO. ,
MAIL �Oa ",TRUNK PERMIT NO. ROAD PERMIT NO.
Date � Applicant � .. ADDRESS iP`r
NOTICE, TO APPLICANT: If, after makingthis Certificate of. AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
CITY -. G (� TEL.,NO. �oW"1
Exemption, you should. becomesubject 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 sholl-be,deemed
revoked. BLOCK TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION ' I 1 NO.OF BLDGS� PERMIT NO.
SIZE OF LOT )C)13 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 `ttiC'"�D(7 LrL0�f AZ/�1"ly - CONNECTION CHARGE FEE Qj
License Number I Lic.Class Q ADDRESS ASM, . . REIMBURSEMENT FEE a
.
Contractor Date 4 / q p DISTRICT NO. GROUP - MAP PROCE ED BY
---:-TI J CITY Wa)- COMMA-,. GA' TEL NO. -/V a7-�1 BK PG
❑ 1 am exem t nder Sec. of the L.A.Co. STATE , n UC.' D �,
P LICENSE NO. f XJ 3 CLASS D�� W
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FI L d
HOUSE SEWER CONNECTING TO .. DAF VALIDATION U)
B. 8 P. Code for the following rBOSOn 'PUBLIC SEWERSEPTIC TANK,SEEPAGE PIT OR FINA
PITS AND/OR DRAINFIELD "
Date BY
HOUSE SEWER CONNECTING TO ' '
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK To HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD
I hereby affirm that I am exempt'from the Contractor's License . . EXTN.,CESSPOOL,DRYWELL,MANHOLE lI '
Low for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM
ElI,as owner of the property,or my employees With wages as - C-FI C- 014tG ACCT.4
their sole compe6sation, will do the work and the structure pmp b j l 2lI.i_li1
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNERIS Permit $ 0 1 ITEMS
❑ I,as owner of the property,am exclusively contracting with AUTIiORIZATION TOTAL FEE TOTAL ® ��
licensed COn1raC10f5 t0 construct the project (Section 7044, 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. CHECK 24■TLI
CONSTRUCTION LENDING AGENCY rL�����['
I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 194•rTt1NGE
_ D ■(_III
for the performance of, the work for which this permit is OWNER OR
issued (Sec..3097, Civ..C.). OWNERS AGENT
tender's Name ADDRESS 0900-0001 .4/26/30
Lenders Address 0333 1 AM'
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, t
and hereby authorize representatives of this County to enter
upon the above-me tinned property for inspection purposes.
Signature ofVittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE