HomeMy Public PortalAbout9914 LIVE OAK AVE_Sewer__ WORKERS'COMPENSATION DECLARAT40N CE 8082(D2-80) I� APPLICATION F®u '� PERMIT
I hereby affirm that d have a certificate of consent to self7SEWER-SEWAGE ®I 7 PO.7A
insure, or a certificate of Workers'Compensation Insurance,or I 'fl
a c r fiedpy the eof Sec. 3800.LLaabb..7C. COUNTY OF LOS ANGELES BUILDING AND SAFETY
PolloIrl %� ompany=cL �C�IIL/_. y
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F1 Certified copy is hereby furnished. FOR APPLICANT TO FILL IN CONNECTION DATA
BUILDING STATION DEPTH
Certified co is filed with the count building ADDRESS �/ 'f � _•
copy y g iUPPER
dMANHOLE REFERENCE�� v �I LOCALITY �, C/ LOWER
Dat ? Applicant - NEAREST TYPE OF CONNECTION LENGTH FROM
CERTIFICATE OF EXEMP FROM WORKERS' CROSS ST. _�/ i:' Y. CURB P.L. M.L. TO P.L.
COMPENSATION INSURANCE .✓ P.C. NO.
OWNER , CO. IMP. NO. JOB NO.
I MAILCL(This section need not be completed if the work involved ADDRESS v9xev TRUNK PERMIT NO. ROAD PERMIT NO. O
by the permit is for one hundred dollars ($100) or less.) U
_ C J AFFIDAVIT WAIVER EASEMENT RECORD. INSTR,NO. DATE
CITY TEL. NO.
I certify that in the performance of the work for which this LEGA tr
permit is issued, I•shall not employ any person in any manner DESCRIPTION LOT NO. HWY. OR ST. WIDENING 0
so as to become subject to the Workers' Compensation Laws. U
BLOCK TRACT STATE ENCROACHMENT W
Date Applicant NO. OF ]SLOGS. NO.
LDGS. �^J N
NOTICE TO APPLICANT: If, after making this Certificate of slzE of Lor Now ON Lor z
Exemption, you should become subject to the Workers' Uof CHARGES
Compensation provisions of the Labor Code, you must forth- Bu1LDINGs
with comply with such provisions or this permit shall be CONTRACTOR CONNECTION CHARGE FEE
deemed revoked. /+J
REIMBURSEMENT FEE
LICENSED CONTRACTORS DECLARATION ADDRE � -7
I hereby affirm that I am licensed under provisions of Chapter CITY JSS r � EL. No. OISrRICr NO. GROUP MAP PROCESSED BY
BK PG
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and STATE LIC.
LICENSE NO. ��� CLASS
effect. NO. DESCRIPTION OF WORK FEE
'7�CQ /� HOUSE SEWER CONNECTING TO FINAL ^ ,` 'VALIDATION
License Number 7 / LIc.Class PUBLIC SEWER DATE
��•✓`�y,7��/J /� _..�. SEPTIC TANK,SEEPAGE PIT OR
j.� �J PITS AND/OR DRAINFIELD
Contractor Date d• FINAL j
J HOUSE SEWER CONNECTING TO BY �..e.a..6.®1 .
❑ PRIVATE DISPOSAL SYSTEM
I am exempt from the licensing requirements as I am a _
CONNECT 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
iness and Professions Code). E%TN.,CESSPOOL,DRYWELL,MANHOLE
ALTER, REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION
�) :7
I ,hereby affirm that I am exempt from the Contractor's OWNER'S Permit s ✓g 8 5'8 A'
License Law,for the following reason (Section 7031.5, Busi- AUTHORIZATIONTOTAL FEE Z) ,j1 0 0io o 1 0
ness and Professions Code): I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- d
aTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING D-.D.
1, as,owner of the property, will do the work and the TO THE PUBLIC SEWER. 12 1.'S G
structure is not intended or offered for sale (Section SIGNED THIS DAV OF 19 0'0 0 ? (�'�
7044, Business and Professions Code). OWNER OR I ,
OWNERS AGENT
CONSTRUCTION LENDING AGENCY 0.104-8-2
I hereby affirm that there is a construction lending agency ADDRESS
for the performance of the work for which this permit is
issued (Sec. 3097,Civ.C.).
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 t is County to enter
upon the above-mentioned property for' pection purpose
— SEE REVERSE FOR EXPLANATORY LANGUAGE
Z.'
S' ure of Permittee ° Date