HomeMy Public PortalAbout10114 LIVE OAK AVE_Sewer__ WORKERS' COMPENSATION DECLARATION
I hereby,affirm that I have a certificate of consent to self 6A64 7 DPW st89
76A64
insure, or b certificate of Workers' Compensation Insurance, or 2D
o cerrif ed copy thereof (Sec 3800, Lab C )
Policy No Company PERM
ffaP UC 7ON F11
SEWER - SSAGE MSPOSALCertified•copy is hereby furnished
❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING,AND SAFETY
department
Date Applicant \ FOR APPLICANT TO FILL IN CONNECTION.DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDRESS D ll i VC STATION DEPTH
(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 VTYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST Y CURB PL M L TO P L
permit is issued, I shall not employ any person In any manner LEGAL
\ so as to become subject to the Workers' Com enSatiOn Laws DESCRIPTION LOT NO - P C NO .
P CO IMP NO PJOB.NO
�-•
DApplicant BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
ote �T �
NOTICE TO APPLICANT If, after makingt Certificate of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
MAP BOOK PAGE PARCEL
Exemption, yo'u should become subject to the Workers' NO OF BLDGS
Compensation provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT HWV QR ST WIDENING
comply with such provisions or this permit shall be deemed ISI CF
revoked BUILDINGS UQiN_L"'P� STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION ' i / ,r_ 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- nooaEss D�� �t /e CHARGES
AIL
ness and Professions Code, and my license is in full force and
effect CITY �j/ TEL NO — Q CONNECTION CHARGE FEE
License Number LIC Class REIMBURSEMENT FEE
CONTRACTOR
Contractor Date DISTRICT NO GROUP MAP PROCESSED BY
ADDRESS `ll BK PG
❑ I am exempt under Sec of the L A CoV }
CITY TEL NO
Plumbing Code and/or Sec of the STATE LIC FINAL V
LICENSE NO CLASS DATE -� VALIDA ION Z
B 8 P Code for the following reason NO- • DESCRIPTION OF WORK FEE O
HOUSE SEWER CONNECTING TO FINAL %�!
Date PUBLIC SEWER BY / 0
• SEPTIC TANK-SEEPAGE PIT OR _ w
Signature PITS AND OR DRAINRaELD �
OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING TOPRIVATE DISPOSAL SYSTEM D Z
I hereby affirm that I am exempt from the Contractor's License2-7 �)
Low for the following reason (Secton 7031 5, Buisness and Pro- wORK To HOUSE SEWER G
fes Ions Code OVERFLOW SEEPAGE PIT DRAINFIELD I�A .i'-�•e
Ip/5• ) ExTN,CESSPOOL DRYWELL MANHOLE -
IBJ I, as owner of theproperty, or m employees with wa es as ALTER.REPAIR OR ABANDON HOUSE '
` Y9 SEWER OR DISPOSAL SV STEM 3307 L'22.j11
their sole compensation, will.do the work and the structure -t
is not intended or offered for sole (Section 7044, Business } 1TEM'S'
and Professions Code)
❑ I, as owner of the property, am exclusively contracting with' Permit $ L �� TOTAL 52 - 70
licensed contractors to construct the project (Section 7044, OWNER'S
Business and Professions Code) AUTHORIZATION TOTAL FEE 10
CHECK 52.7 )
CONSTRUCTION LENDING AGENCY i HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO CHANGE v00
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 DAYOF 19_ i f �, ;
OWNER OR iJi1 L1 J
Lender's Name OWNERS AGENT �FIJ/ AM,1 : 1
Lender's Address 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 above- entioned property for inspection purposes
Signature of Pe ittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE