HomeMy Public PortalAbout5710 KAUFFMAN AVE_Sewer__ 9 t,:,NORKERS' COMPENSATION DECLARATION
I hereby affirm ihat"i have S certificate of consent to self U
insure, ora certificdie of Workers'Compensation Insurance, or 76A642D (J
a certified copy thereof (Sec. 3800, Lab C.) CE 808(REV.1/83) APPLICATION FOR PERMIT
Policy No. Company
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND.SAFETY
department. ��^t
Date ' C' _ __Applicant � FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATIONDEPTH +
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work involved by the _ t C MANHOLE REFERENCE UPP
permit is for one hundred dollars ($100)or less.) LOCALITY 1 c' x , ER
NEAREST TYPE OF CONNECTION IFNGTH FROM
I certify that in the performance of the work for which this CROSS ST. Y. CURB P.I. M.I.TO P.I,
permit is issued, I shall not employ any person in any manner
P.C.NO.
so as to become subject tothe Workers'Compensation LAWS. OWNER CO.IMP,NO. JOB NO.
' MAIL
S TRUNK PERMIT NO. ROAD PERMIT NO.
Date a Applicant //�%` (: (�. rel hdi' ADDRESS
AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
NOTI E ,TO APPLICANT: If, after making this Certificate of CITY t
Exemption, you should become subject to the Workers' �rTEL.No.
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 STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO. r(7 yJ
C'
I hereby affirm that I am licensed under provisions of Chapter SIZE OF LOT NOW ON LOT 364 USE OF �7
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 Lic.Class ADDRESS ! @ REIMBURSEMENT FEE 5y
DISTRICT NO. GROUP MAP PROCESSED BY
Contractor Date CITY T L.NO. ` (p `
❑ I am exempt under Sec. of the L.A.Co. BK PG
STATE /L uc. J,4 j�, 2 �-- 0
P LICENSE NO. O CLASS J\ J
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL
-HOUSE SEWER CONNECTING TO a J DATE VALIDA N
B. & P. Code for the following reason PUBLIC SEWER
SEPTIC TANK,SEEPAGE PIT OR FINAL �'
PITS AND/OR DRAINFIELD BY
DQt HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM -
Signature CONNECT ADDITIONAL BLDG.OR ,
O NER-BUILDER DECLARATI N WORK TO HOUSE SEWER
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, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM .
❑ I,as owner of the property, or my employees with wages as
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 $LI
❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION I TOTAL FEE 4.7 3 2 A
licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONT—L-1- TO
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. O O 0�1 0
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency SIGNED THISDAY OF 19 ► ®.°'2 7 5 0
OWNER OR �/
for the performance of the work for w %1 ehich this permit is OWNERS AGENT 04 Z-°'.' Zi` ° ° ° 2 7 5 0 cit
issued (Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
5
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 hereby authorize representatives of this County to enter
upon the abor-mentioned property for inspection purposes.
.
Signature of Permittee Note SEE REVERSE FOR EXPLANATORY LANGUAGE