HomeMy Public PortalAbout6032 KAUFFMAN AVE_Sewer__ WOR20-0057 DPW 6189
KERS' COMPENSATION DECLARATION C�
I herebye affirm that I have o certificate of consent to self
u
insure, T a certyfscate bf Workers' Compensation Insurance, or 76A642D
,,a A?rttified copy thereof (Sec. 3800, Labc%) APPLICATION FOR PERMIT
Policy No, .• Company ��� u4� SEWER - SEWAGE DISPOSAL
[ Ce'rtified copy is hereby furnished.
❑ Certified copy is filed with the county bqdinqnspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING p 1
DEPTH
COMPENSATION INSURANCE ADDRESS STATION L��eV2
(This section need not be completed if the work involved by the MANHOLE REFERENCEL LOWER PER_
permit is for one hundred dollars ($100) or less.) LOCALITY .� y- �/ •3
NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. Y CURB P L M L TO P L
permit is issued, 1 shall not employ any person in any manner LEGAL
so as to become subject to the Workers' Compensation Laws. DESCRIPTION LOT NO. C NO
CO IMP NO JOB NO
Date Applicant BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
NOTICE TO APPLICANT: If, after makingthis Certificate Of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
MAPBOOK PAGE PARCEL
Exemption, you should become subject to the Workers' NO.OF BLDGS.
Compensation provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT HWY OR ST WIDENING
comply with such provisions or this permit shall be deemed USE OF
revoked. BUILDINGS STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION PERMIT NO
I hereby affirm that I am licensed under provisions of Chapter OWNER
9 (commencing with Section 7000) of Division 3 of the Busi- MAIL +� _ j�( �v� CHARGES
ness and Professions Code, and mJ license is in full force and ADDRESS
+; CONNECTION CHARGE FEE
effect.
License Number ^% y CITY `^7 1 TEL.NO. '7M Lic.Class M1 _�7 REIMBURSEMENT FEE
� CONTRACTOR
Contractor it/ 1 Date 4- -30 �� ADDRESS I _�AEA r,s W � a.-k� DISTRICT NO GROUP BK MAP PG PROCESSED BY
i _
❑ I am t exem under Sec. of the L.A.Co. 7 f J 9 �C / lf�J
p CITY L(A;• tl TEL.NO. r f `A L � /" • '111/
Plumbing Code and/or Sec. of rhe STATE f;� LIC. _ FINAL
LICENSE NO. j." CLASS _ �jr=' DATE `���3_-/r'� VALIDATION 00Z
B. & P. Code for the following reason NO. DESCRIPTION OF WORK FEE /
HOUSE SEWER CONNECTING 70 HNAL h
Date PUBLIC SEWER t BY 0
SEPTIC TANK SEEPAGE PIT OR Lll
a
Signature PITS AND OR DRAINFIELD �
OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING TOPRIVATE DISPOSAL SYSTEM Z
I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR
Law for the following reason (Secton 7031.5, Buisness and Pro- WORK TO HOUSE SEWER _
fessions Code): OVERFLOW SEEPAGE PIT,DRAINFIELD +�
EXTN.CESSPOOL DRYWELL,MANHOLE i•^ "`
••'`"§ °T
❑ ALTER I,as owner of the property, or my employees with wages as sewEa REPAIR OR ABANDON HOUSE
OR DISPOSAL SYSTEM
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business
and Professions Code).
❑ I, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Section 7044, OWNERS Permit
Business and Professions Code). AUTHORIZATION TOTAL FEE :_:mai
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR To t^.`=;,•��Y,, , `(
I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER
for the performance of the work for which this permit is
issued (Sec. 3097, Civ. C.). r SIGNED THIS DAY OF 19_
�f�7r�-C_. OWNER OR %! i i,_I f )
Lender's Name OWNERS AGENT i
Lender's Address ADDRessiiw
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1 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 above- ned property for inspection purposes.
i
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE