HomeMy Public PortalAbout5936 LOMA AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm, that I have,.o certificate of cpnsent to self
inure, or a c�Yific,5re of'Workers'-Compensation Insurance, or 76A642D
a certified copy thereof(Sec. 3800, gab C.j T n 92-0002 DPW 6/88
APPLICATION FOR PERMIT
•Policy No. Company S �TI'r..u�aoX. /'�
Certified copy is hereby furnished. SEWER SEWAGE DISPOSAL
El
Certified copy is filed with the county building inspection COUNTY.OF LOS ANGELES BUILDING AND SAFETY
departnieni.
Date pd .Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING:
COMPENSATION INSURANCE } ADDRESS STATION DEPTH
(This section need not be completed if the work involved by the LOCALITY MANHOLE REFERENCE LOWER
permit is for one hundred dollars ($100)or,less.)
I certify that in the performance of NEAREST TYPE OFC LENGTH FROM
the work for which this CROSS ST. L Q Y. CURB P.I. M.L.TO P.L.
employ any person in any manner
permit is issued, I shall not e
so as io become subject to the Workers'Compensation LOWS OWNERSz P.C.NO.
CO.IMP.NO. JOB NO:
• �. MAIL -
ADDRESS - ' TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant
NOTICE, TO •APPLICANT: If, after makingthis of. AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.No. DATE
'CITY TEL NO.
Exemption,. you should become subject to the Workers' LEGAL I
.Compensation provisions of:the Labor code, you must forthwith DESCRIPTION LOT NO. t HWY.OR ST.WIDENING
comply.with such provisions or this permit shall be deemed
revoked. , BLOCK TRACT - - STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO.of LOT PERMIT No.
SIZE OF LOT^. � NOW ON LOT -
I hereby affirm that I am licensed under provisions of Chapter USE OF
9 (commencing with Section 7000) of Division 3 of the Busi BUILDINGS CHARGES
ness and Professions Code, and my license is in full force and
effect. CONTRACTOR' CONNECTION CHARGE FEE
'.License Number Lic.Class G REIMBURSEMENT FEE
ADDRESS .
'.COnlraCtOr �!iY�7�/ -. Date ���'�b clrY TEL.NO. ,Z 6 DISTRICT NO. GROUP. MAP - OCES ED BY �.
c5y�(J �j K PG
❑ I ac exempt under Sec. of the L.A.Co. CCENSE NO. CLASS G- UlVLIC. xl ✓
Plumbing Code and/or Sec: of the NO. DESCRIPTION OF WORK FEE FINAL Cn
- ' HOUSE SEWER CONNECTING TO 1 DATE 1A)DAT IN - fn
B. 8 P. Code for the following reason
PUBLICTICTANK,
SEPTIC TANK,SEEPAGE PFf OR
_ PITS AND/OR DRAINFIELD- FINAL
Date BY
HOUSE SEWER CONNECTING TO - -
PRIVATE DISPOSAL SYSTEM -
Signature CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK.TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD
I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE
Lawfor the following reason(Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE 11J
fessions Code): - SEWER OR DISPOSAL SYSTEM + i<
as owner of the property,or my employees with wages as. t' '1 `g
their sole compensation, will do the work and the structure ij( 14m'50
is not intended or offered for sale (Section 7044, Business Permjt 5 v/ n
and Professions Code). OWNER'S -. 1 ITEM
l:M
❑ I,'as owner of the property,am exclusively contracting with AUTHORIZATION rTOiAL FEE
licensed contractors to construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE-HEREIN NAMED C R TOTAL 3 �_
Business and PfofessiOnS Code). - CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUB i � 0. 5il
CONSTRUCTION LENDING AGENCY CHECK
I hereby affirm that there is a construction lending agency OWNER SIGNED THIS DAY OF {. "Ltlf� -00-00for the performance of the work for which this permit is
OWNERS A AGENT
.issued (Sec.'3097, Civ. C.). _ �'
Lender's Name ADDRESS L 16/
fj[ll—i Eli 5 I
3
,y �`nI
.Lender's Address 1370,E 1 AN L} L,-
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 autho a representatives of this County to enter
upon the.abov boned property for inspection purposes.
Signa ure of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE