HomeMy Public PortalAbout9437 KENNERLY ST_Sewer__ WORKERS'COMPENSATION DECLARATION - D
CE-808
(2-80)" APPLICATION FOR PERMIT
CE 808
I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy3800,Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No WN �Compa ny / yYl
FOR APPLICANT TO FILL IN CONNECTION DATA
ElCertified copy is hereby furnished.
BUILDING STATION DEPTH
El Certified copy is filed with the county building inspection ADDRESS AI
UPPER
department' LOCALITY MANHOLE REFERENCE LOWER
Date Applicant NEAREST TYPE OF CONNECTION LENGTH FROM
CERTIFICATE OF EXEMPTION FROM WORKERS' cRoss sr. G`Qd Y. CURB P.L. M.L To P.L.
COMPENSATION INSURANCE P.C. NO.
OWNER CO. IMP. NO. JOB NO.
(This section need not be completed if the Work involved MAILADDRESS TRUNK PERMIT NO. ROAD PERMIT NO. >_
by the permit is for one hundred dollars ($100) or less.) (-
AFFIDAVIT WAIVER EASEMENT RECORD, INSTR. NO. DATE
CITY L. NO. O
I certify that in the performance of the work for which this LEGAL
permit is issued, I,shall not employ any person in any manner DESCRIPTION LOT N HWY. OR ST. WIDENING
so as to become subject to the Workers' Compensation Laws. 0
BLOCK TRACT STATE ENCROACHMENT
Date Applicant NO. OF BLDGS. PERMIT NO.
LU
NOTICE TO APPLICANT: If, after making this Certificate of sizE of LOT Now oN LOT d.
Exemption, you 'should• become subject to the Workers' USELOF , CHARGES Z
Compensation provisions of the.Labor Code, you must forth-
with comply with such provisions Or this permit Shall be CONTRACTOR — CONNECTION CHARGE FEE
deemed revoked. anz
REIMBURSEMENT FEE
LICENSED CONTRACTORS DECLARATION ADDRESS - Q� f�J
I hereby affirm that I am licensed under provisions of Chapter DISTRICT NO. GROUP MAP PR ocesSED BY
9 (commencing with Section 7000) of Division 3 of the Busi- CITY yJf�L� Cl' EL. NO. r BK PG
ness and Professions Code, and my license is in full force and STATE LIC.
effect. LICENSE NO.. d CLASS
NO. DESCRIPTION OF WORK FEE
,�/ �_�
40HOUSE SEWER CONNECTING TO- FINAL fVALIDATION
License'Number `40! 7 Lic. Class PUBLIC SEWER DATE 1
G� SEPTIC TANK,SEEPAGE PIT OR
Contra Ct Ori F Date
��� r(J]Y PITS AND/OR DRAINFIELD
FINAL
HOUSE SEWER CONNECTING TO BY /
PRIVATE DISPOSAL SYSTEM
I am exempt from the licensing requirements as I am a v
CON"ECT ADDITIONAL BLDG.OR
licensed architect or a registered professional engineer WORK TO HOUSE SEWER
acting in my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT,DRAINFIELD
Ines$and Professions Code). EXTN.,CESSPOOL,DRYWELL, MANHOLE
ALTER, REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
Lic.or Reg.No. Date
HOMEOWNER-BUILDER DECLARATION
OWNER'S Permit s
I hereby affirm that 1 am exempt from the Contractor's 2,4!7 Jr,.5 A
License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE
ness and Professions Code). # o Io 0 0 O
1 HAVE AT TMIS DATE A CONTRACT WITH THE HEREIN NAA D CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED
RIB EO EXISTING WELLING
[, as owner of the property, will do the work and the TO THE PUBLIC SEWER. o o ],5 O
structure is not intended or offered for sale (Section SIGNED THIS DAY OF 19_
7044, Business and Professions Code). OWNER OR j7,5 O=
OWNERS AGENT OHO O U
CONSTRUCTION LENDING AGENCY ADDRESS
I hereby affirm that Were is a construction lending agency O 7t O 2'-8 2
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.G.)
Lender's Name
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
u=eaboventioned p;qppay for Inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date