HomeMy Public PortalAbout9532 LIVE OAK AVE_Sewer__ WORKERS'COMPENSATION DECLARATION / /''•/�f,/�`� �� !
I hereby affirm that I have a certificate of consent to self
insurel or p certificate of Workers'Compensation Insurance, or 76A642D LS
o�gf5ytitbefe(/Cp / > �/,r®3 DB(REV B,B,) APPLICATION. FOR PERMIT
Ic❑ c tlfled(c�ojp'y Is hereby furnished SEWER - SEWAGE DISPOSAL _
Certified copy Is filed with the county building Inspect) COUNTY OF LOS ANGELES BUILDING AND SAFETY
depftENSATION
Dapllcant ? FOR APPLICANT TO FILL IN CONNECTION DATA
F EXEMPTION FRO ORKERS' BUILDING +�INSURANCE ADDRESSUPPER
STATION DEPTH
(This section need not be completed if the work Involved by the LOCALITY t�q�t U� MANHOLE REFERENCE OWER
permit Is for one hundred dollars ($100)Or Ie55 ) NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that In the performance of-the work for which this CROSS S rJ Y CURB P L MIL TO P L >-
permit Is Issued, I shall not employ any pbrson In any manner PC NO 8.
so as to become subject to the Workers'Compensation Laws OWNER vCO IMP NO JOB NO 0
MAIL l TRUNK PERMIT NO "ROAD PERMIT NO gg
Date Applicant ADDRESS
AFFIDAVIT I WAIVER EASEMENT RECORD INSTR NOr DATE O
NOTICE TO APPLICANT If, after making this Certificate of CITY TEL NO
Exemption, you should become subject to the Workers' LEGAL su
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 — N
revoked BLOCK TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO OF BLDGS PERMIT NO
SIZE OF LOT NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter USE OF j
9 (commencing with Section 7000) of Division 3 of the Busl- BUILDINGS v CHARGES
-- ness and Professions Code,-and-my license is,ln full force and _ _
effect�l,J CONTRAC -�� -CONNEGTION CHARGE FEE--• -- - _ _ _s__
LlceenseA'POf-f1bey7 �" LIC Class C— ADDRESS REIMBURSEMENT FEE
DISTRICT NO GROUP MAP PR ESSED�B.YY //-§
'-� Date CI TEL NO � CJ
BK PG
❑ I am exem t under Sec of the L A Co STATE tI _ 0,
P LICENSE NO ASS G L
Plumbing Code and/or Sec of the NO D CRIPTION OF WORK FEE FINAL
HOUSE SEWER CONNECTING TO DATE / 4VALIDATION
B 8 P Code for the following reason PUBLIC SEWER
SEPTIC TANK,SEEPAGE PIT OR FINAL
PITS AND/OR DRAINFIELD
Date BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG OR Poo-
Low
DECLARATION WORK TO HOUSE SEWER
PITI hereby affirm that I am exempt from the Contractor's License EOXTNFLOW SEEPAGE OL DRYWEDLRLAMANHINFIELOLE
Law for the following reason (Sectors 7031 5, Buisness and Pro- ALREPAI R ABANDON HOUSE
fessions Code) SEWER POSAL SYSTEM Z19 5 9. 21A
. 2 1-1
!1
El `
j,as owner of the property, or my employees with wages as
their sole compensation, will do the work and the structure # o o 0 0 O
is not intended or offered for sale (Section 7044,Business
and Professions Code) OWNERS Permit g ((� 2'0;0 2 1.50
❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE v 'o'o,a 2 1,5 0.6
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO } zz�
Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER O U O 9—84
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
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
or a�Tances and State laws regulating Plumbing and Sewers,
nd hereby authonze representatives'of th 'County to enter
ue he above-menti ned op>�for In ection purpo s
Signatur of Permittee Dat SEE REVERSE FOR EXPLANATORY LANGUAGE