HomeMy Public PortalAbout6139 KAUFFMAN AVE_Sewer__ WORKERS' COMPENSATION DECLARATION
I hereby pffirrr�hat I have A certificate of consent 'to,-self 76A642 DPW 6/89
Insvre,�o4 a.cet If icate of Workers' Compensation Insumrice, or 76Asa2D
a certified copy thereof (Sec. 3800, Lab C) ( APPLICATION [AOR PERMIT
Policy No.AnX�Company
ertifie--d''copy is hereby furnished. SEWER - SEWAGE DISPOSAL
❑ Certified copy is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Date f0-- Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CE T FIf CATE OF EXEMPTI FROM WORKERS' BUILDING �l STATION DEPTH
COMPENSATIO INSURANCE ADDRESS V
(This section need not be completed if the work involved by the MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY ♦ LOWER
NEAREST 4r 11 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, I shall not employ any person in any manner LEGAL PC NO
so as to become subject to the Workers' Compensation Laws. - DESCRIPTION LOT NO. CO IMP NO JOB NO
1
BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of ASSESSOR f gAFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
9 MAP BOOK � PAGE 4:�/ PARCEL;(7�
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
PERMIT No
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter OWNER
9 (commencing with Section 7000) of Division 3 of the BUsi- MAIL f CHARGES
ness and Professions Code, and m,/license is in full force and ADDRESS
effect. CITY L.NO. CONNECTION CHARGE FEE
License Number LIC. Class TREIMBURSEMENT FEE
CONTRACTOR C 'i
Cant/OC10r Date DISTRICT NO GROUP MAP PROCESSED BY
ADDRESS � SK PG
❑ I am exempt under Sec. o the L.A. Co. J; 1L �� `j �� 3 > d
CITY TEL.NO. ' a++ p
Plumbing Code and/or Sec. of the STATE LIC. FINAL U
LICENSE NO. CLASS 1, DATE !�{�. /1 VALIDATION Z
B. 8 P. Code for the following reason NO. ESCRIPTIO OF WORK FEE ( ` Q
HOUSE SEWER CONNECTING TO ��FINAL / 1—
Date PUBLIC SEWER �, PY V
SEPTIC TANK SEEPAGE PIT OR W
Signature PITS AND OR DRAINHaELD N
OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM
I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR �s
Law for the following reason (Secton 7031.5, Buisness and Pro- WORK TO HOUSE SEWER -=
fessions Code): OVERFLOW SEEPAGE PR DRAINFIELD ' •j•`a A
EXTN.CESSPOOL.DRYWELL.MANHOLE 1-f
❑ 1,as owner of the property, or my employees with wages as ALTER.REPAIR OR ABANDON HOUSE ;-i-
SEWER OR DISPOSAL SYSTEM -.,D.Fig -,`_`'_'
their sole compensation, will do the work and the structure "
is not intended or offered for sale (Section 7044, Business1 1€1 N!;
and Professions Code). ____.• .,••__
1, as owner of the property, am exclusively contracting with `•U l HL
El
licensed contractors to construct the project (Section 7044, OWNERS Permit $ _:
f.H�..{.K
Business and Professions Code), AUTHORIZATION TOTAL FEE _
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED ONTRACTOR TO ® L_• !i(7 _=LI_I
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.). SIGNED THIS DAY OF 19_ �i,)3- -�s
OWNER OR
Lender's Name OWNERS AGENT 0980 1• E E J 9 F •
Lender's Address ADDRESS
r
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 above-mentioned property for inspection purposes.
'-
ature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE