HomeMy Public PortalAbout9464 LEMON AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
I,hereby -off ,m that I have a certificate of consent to self 92-0002 DPW 3/87
u
Insure, or a certificCE 808
ate of Workers'Compensation Insurance, or D
a certlfiei copy thereof (Sec 3800, Lab C ) CE 808 APPLICATION FOR PERMIT
Policy No Company ®s `
❑ 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
Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING / STATION i O DEPTH
COMPENSATION INSURANCE ADDRESS (Q / v�
(This section need not be completed If the work Involved by the LOCALITY MANHOLE REFERENCE �7o Lv, UPPER
permit Is for one hundred dollars ($lOO)Or Ie55 ) LENGTH FROM
I certify that in the performance of the work for which this
NEAREST
ROSS ST TYPE OF CON oN
Y COM
B P L ML TOPIL
FROM
permit Is Issued, I shall not employ any person In any manner /�A• PC NO
_J V
so as to become subject to the Workers'Compensation Laws OWNER C V' CO IMP NO JOB NO
MAIL TRUNK PERMIT NO ROAD PERMIT NO
Date Applicant ADDRESS
NOTICE TO APPLICANT' If, after making this Certificate of C1ty _tEL NO WAIVER EASEMENT RECORD INSTR NO DATE
�� J
AFFIDAVIT
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
revoked BLOCK TRACT STATE ENCROACHMENT'.
LICENSED CONTRACTORS DECLARATION No of PERMIT NO
LOT
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 CONTRACTO CONNECTION CHARGE FEE
License Number LIC Class ADDRESS REIMBURSEMENT FEE d
O
Contractor DateDISTRICT NO GROUP MAP PROCESSED BY V
CITY TEL NO BK PG Z
STATE LIC 0
❑ I am exempt under Sec of the L A Co LICENSE NO CLASS -pf 3 /pao
U
Plumbing Code and/or Sec of the NO DESCRIPTION OF WORK FEE FINAL
HOUSE SEWER CONNECTING TO DATE VALIDATION Lu
B & P Code for the following reason PUBLIC SEWER CL
SEPTIC TANK,SEEPAGE PIT OR FINAL U)
PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signature ONNECT ADDITIONAL BLDG OR �Z
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
I hereby affirm that I am exempt from the Contractor's License EOxiN FLOCESS SPOOL,DRVWEDLRL,41MANHOLE A. t rtF
Law for the following reason (Sectors 7031 5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code) SEWER OR DISPOSAL SYSTEM '•_'I C=o
❑ I,as owner of the property,or my employees with wages as fL
their sole compensation, will do the work and the structure
s not Intended or offered for sale (Section 7044, Business c
and Professions Code) OWNER'S Permit '=
I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO -
BUSIne55 and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING t0 THE PUBLIC SEWER
CONSTRUCTION LENDING AGENCY
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 A [t1;1:'i
p p OWNERS AGENT -
issued Sec 3097, Civ CK'H'j—
F, -:
ADDRESS
Lender's Name —
Lender's Address
I certify that I have read this application and state that the
above int rmation Is correct I agree to comply with all County
ordinances and State I s regulating Plumbing and Sewers,
an re authorize r re entad s of this County to enter
On t bove-mentio cl Or ins CtlOn purpo es -
re of ermlttee D e �, �� SEE REVERSE FOR EXPLANATORY LANGUAGE