HomeMy Public PortalAbout9103 LAS TUNAS DR_Sewer__ WORKERS' COMPEN ATION DECLARATION
20-0051 DPW 6/89
I hereby affirm that I ho a certificate of conse to self
insure, or a certificate o orkers' Compensation I urance, or 76ABa2D
o certified co y there (Sec. 3800, Lab ) APPLICATION FOR PERMIT
PolicyfN Company S �'
ElC> (4fi d py is hereby furnished. SEWER - SEWAGE DISPOSAL
❑ Clert_i ' d copy is filed with th ounty buildingDction COUNTY OF-LOS ANGELES BUILDING AND SAFETY
d artment.
r
D e Apph nt FOR APPLICANT TO FILL IN, CONNECTION DATA
CERTIFICATE EXEMPTIO FROM WORKERS' BUIL G
MPENSATION INSURANCE ADDRESS STATION DEPTH
(This section d not be completed if the work involved by the MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY LOWER
I NEAREST All 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
''p�J mmaannner LEGAL P C NO
so as to become subject to the ers' Compensatio S DESCRIPTION LOT NO. CO IMP No JOB NO
Q®^ BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
Date a/ Applicant
NOTICE TO APPLICANT: If, after akin this Certificate O ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
g MAPBOOR 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
PERMIT NO
LICENSED CONTRACTORS DECLARATION A
I hereby affirm that I am licensed under provisions of Chapter
OWNER �'.
9 (commencing with Section 7000) of Division 3 of the Busi- MAILADDRESS CHARGES
ness and Professions Code, and my license is in full force and pb 9 tl g� p�
effect. 2Q� {�'9 CITY TEL.NO. 2/•b`' 91-3- 4J CONNECTION CHARGE FEE
License Number .JV -�d+d Lic.Class 4-2. b �,�F/.A�f REIMBURSEMENT FEE
�®p,,((,� �� CONTRACTOR a DISTRICT NO GROUP MAP PROCESSED BY
Contra Ctor/ lhymwdiQ 49�`b (C?!. A / -
ADDRESS Cj L asj' L..y �J BK PG
❑ I am exempt under Sec. of the L.A.Co. CITY AJ&ri EL.NO. � 'P, P L+ p/OV 0
O
Plumbing Code and/or Sec. of the STATE h_ LIG. �' FINAL U
LICENSE NO,.," ~q.5"I 9r�CLASS � • Jam. DATEYf VALIDATION Z
B. 8 P. Code for the following reason NO. 1 DESCRIPTION OF WORK FEE lJ�Q g L•s(J O
HOUSE SEWER CONNECTING TO FINAL {•'-
PUBLIC SEWER BY U
W
t SEPTIC TANK.SEEPAGE PIT OR d
Signature y• PITS AND OR DRAINFIELD U)
OW -BUILDER DECLARATION HOUSE SEWER CONNECTING To , Z
PRIVATE DISPOSAL SYSTEM —
I hereby affirm tho 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 SEWERS i
OVERFLOW SEEPAGE PIT.DRAINFIELD
fesslons Code): EXTN CESSPOOL.DRYWELL.MANHOLE :�I.i-• ,��
❑ I, as owner of the property, or my employees with wages as ALTER SEWER REPAIR OR DIS OSALBANDOM HOUSE
their sole compensation, will do the work and the structure
is not intended or offered for sole (Section 7044, Business
and Professions Code).
❑ I, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Section 7044, OWNER'S Permit $
Business and Professions Code). AUTHORIZATION TOTAL FEE 6 -•t a:
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
I herebyaffirm that'there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER d-'L t-•jj:E e I4
9 9 Y �:C7f?::_
for the performance of the work for which this permit is
issued (Sec. 3097, Civ. C.). SIGNED THIS DAY OF 1'9_
OWNER OR _
Lender's Name OWNERS AGENT i iu I iI a—LiI }_ { _I
I ADDRESS :: - A _••`-g
Lender's Address It
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 abyoovye---mmeJ�nnttion;jkropertypffoorr inspection
purposes.
Sig Lure of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE