HomeMy Public PortalAbout9218 LIVE OAK AVE_Sewer__ WORKERS' COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to self 20-0057 DPW 6189
insure, or a certificate of Workers' Compensation Insurance, or 76A6420
o certified copy thereof (Sec. 3800, Lab C. ®®PLIC TIO' F®® PERMIT
Policy No. Company �—a■ �p� �—e y �A PERMIT
�1I■ i
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Dote Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDINGLr O ` STATION �'� V. 3 DEPTH
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work involved by thea MANHOLE REFERENCE f��Q� ���
PIP
permit is for one hundred dollars ($100)or less.) LOCALITY w
NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this GROSS ST. Y CURB P L M L To P L 3
permit is issued, 1 shall not employ any person in any manner LEGAL PC NO
so as to bJJJecome subject to the Workers' Compensation Laws. DESCRIPTION Lor NO. CO IMP NO JOB NO
// "� BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
Date Applicant /
NOTICE TO APPLICANT: If, after makin + is Certificate of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
g MAP BOOK PAGE Ci �� 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
LICENSED CONTRACTORS DECLARATION PERMIT NO
1 hereby affirm that I am licensed under provisions of Chapter
OWNER C t
9 (commencing with Section 7000) of Division 3 of the Busi- MAIL CHARGES
Hess and Professions Code, and m)/license is in full force and ADDRESS
effect. CITY TEL.NO. CONNECTION CHARGE FEE
License Number Lic.Class REIMBURSEMENT FEE
CONTRACTOR
Contractor Date DISTRICT NO GROUP MAP PROCESSED BY
ADDRESS BK PG
❑ I am exempt under Sec. of the L.A. Co. n ^n }
CITY TEL.NO. �o J - / O O
Plumbing Code and/or Sec. of the STATE LIC. FINAL U
LICENSE NO. CLASS DATE y�1 VALIDATION
B. 8 P. Code for the following reason NO. DESCRIPTION OF WORK FEE G 3 Q
HOUSE SEWER CONNECTING TO FINAL (✓
Date PUBUC SEWER O BY O
SEPTIC TANK. SEEPAGE PIT OR W
Signature PITS AND OR DRA WaFIELD CID
OWNER-BUILDER DECLARATION HOUSE SEWER c ro Z
PRIVATE DISPOSALL SYSTEM SYSTEM
I hereby affirm that I Om exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR
Law for the following reason (Secton 7031.5, Buisness and Pro- WORK TO HOUSE SEWER #_
fessions Code): OVERFLOW SEEPAGE PIT, DRAINFIELD „•„,_
EXTN,CESSPOOL,DRYWELL,MANHOLE
LA I, as owner of the property, or my employees with wages OS ALTER REPAIR OR ABANDON HOUSESEWER OR DISPOSAL SYSTEM
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business ; T
and Professions Code). s IL `'—`
❑ I, as owner of the property, am exclusively contracting with Permit $
licensed contractors to Construct the project (Section 7044, OWNER'S (' r
Business and Professions Code). AUTHORIZATION TOTAL FEE s-•HEC"I""'
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED ONTRACTOR TO
I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER t'Hf•'fNIGiit
for the performance of the work for which this permit is
issued (Sec. 3097, Civ. C.). SIGNED THIS DAY OF 19_ y�g_ +y _
OWNER OR �',L^-iri
Lender's Name OWNERS AGENT '+'-•
Lender's Address ADDRESS All s_: 41
1 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.
Signatre- f Pe mit ee Dcyfe SEE REVERSE FOR EXPLANATORY LANGUAGE