HomeMy Public PortalAbout10212 LIVE OAK AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
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• I here�yt•rffnm•-,yiat I have a certificate
DPW 3/87,
flcate of consent to self ' _
(1a certificate of Workers'Compensation Insurance, or 76A642D
808
a certified copy thereof (Sec 3800, Lab C ) CE n PIS() C/n1�� ON FOR 4P(E'R( 97
Policy No Company es b=ALI I�elsps /i=�1 pp�IlV 111 u LSA+ tJC/u
❑ Certified copy Is hereby furnished SEWER - SEWAGE ®OSP®SAL
❑ 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' BUILDINGI /� STATION DEPTH
COMPENSATION INSURANCE' ADDRESS
(This•section need not be completed if the work Involved by the n!(: { MANHOLE REFERENCE UPPER
permit Is for one hundred dollars ($100)or less ) LOCALITY 7 0 !f C ) LOWER
I certify that In the performance of the work for which this CROSSSST ,C l Y TYPE OF CONNECTION MIL LENGTH FROM
CURB PL ML TOPL'
permit Is Issued, I shall not employ any person in any manner
so as to become subject to the Workers' Co pe oton Law owNER L`QNO
-{-{ 1' ,�`� �`�v�t co IMP NO JOBPC NO
MAIL '� ' TRUNK PERMIT NO ROAD PERMIT NO
Date Applicant !.6 ADDRESS W 1 Q�� (�� f c
_ NOTICE TO APPLICANT If, after making This ertiflcate of CITY Vr)fEL NO
r AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
Exemption, you should become subject, to the Workers' -LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO HWY OR'ST WIDENING
comply with such provisions or this permit,shall be deemed s
revoked BioCK TRACT S STATE ENCROACHMENT
OF BLDGS PERMIT NO
NO
LICENSED CONTRACTORS DECLARATION SIZE oFLOT NOW ON OF BLOT
hereby affirm that I am licensed under provisions of Chapter USE OF
9 (commencing with Section 7000) of,Division 3 of the BUST- BUILDINGS CHARGES
ness and Professions Code, and my license Is In full force and
effect CONTRACTOR CONNECTION CHARGE FEE
License Number LIC,Class ADDRESS REIMBURSEMENT FEE O
Contractor Date' DISTRICT NO GROUP MAP PROCESS D BY 0
CITY TEL NO n PG z
❑ I am exempt under Sec of the L A.Co
STATE el LIC LICENSE NO CLASS B c
NO DESCRIPTION OF WORK FEE
r Plumbing Code and/or Sec of the- FINAL U
' HOUSE SEWER CONNECTING TO DATEVALIDATI W
B & P Code for the following reason PUBLIC SEWER CL
SEPTIC TANK,SEEPAGE PIT OR FINAL Z_
PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signature 'CONNECT ADDITIONAL
WORK TO HOUSE EWER BLDG OR
i
OWNER-BUILDER DECLARATION
OVERFLOW SEEPAGE PIT,DRAINFIELD •
I hereby affirm that I am exempt from the Contractor's License EXTN,CESSPOOL,DRYWELL,MANHOLE
Law for the following reason (Secton 7031 5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
feSSI ns Code) SEWER OR DISPOSAL SYSTEM �c 9 Q 6.4 A-
LJ JI,
as owner of the property,or my employees with wages as # o e-e Oil 0
their sole compensation, will do the work and the structure e - 21.50
Is not Intended or offered for sale (Section 7044, Business Permit $ e o 0 2,1.5
and•Professions Code) OWNERS
❑ I, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE 0226,-- 88
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER '
CONSTRUCTION LENDING AGENCY D
I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_
for the performance of the work for which this permit Is OWNER OR
issued (Sec 3097, Civ C ) OWNERS AGENT
ADDRESS
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
upon the bove-m ntione roperty or Inspection purposes
r
Signature of Perm ee Date SEE REVERSE FOR EXPLANATORY LANGUAGE