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HomeMy Public PortalAbout9534 LIVE OAK AVE_Sewer__ II WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance, or 76A642D LS a Certified opy thereof (Sec. 3800, Lab C.) CE 808(REV.B/81) APPLICATION FOR PERMIT Polite No. Co jp�ny " j A'\��WJ _ ©s Certified copy is here�'Yurnished. SEWER - SEWAGE DISPOSAL ®.,Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. r _ Dote _ plicant k� 45;IS1 0 E_ , 1,Cho FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING �,� O� STATION DEPTH COMPENSATION INSURANCE ADDRESS 1✓ This section need not be completed if the work involved by MANHOLE REFERENCE the UPPER permit is for one hundred dollars ($100)or less.) LOCALITY C a LOWER NEAREST r,• - .�. TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS 5T. 4y Y. CURB• P.L. M.L.TO P.L. permit is issued, I shall not employ any person in any manner subject to the Workers' Compensation Laws. P.C.NO. so as to become sub I p OWNER � � Jr CO.IMP.NO. JOB NO. MAIL TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS NOTICE TO APPLICANT: If, after makingthis Certificate o{ AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE CIT� EL.NO. tp Exemption, you should become subject to the WorkersLEGAL 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 BLDGS. PERMIT NO. I hereby affirm that I am licensed under provisions of Chapter SIZE OF LOT NOW ON LOT u5E OF 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS � `i { 1 CHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTOR CONNECTION CHARGE FEE p License Number4(� Lic.Class e>_ ADDRESS REIMBURSEMENT FEE C. Contractor\ ,le 1�� Date � — DISTRICT NO, GROUP MAP PROCESSED BY CITY TEL.NO. / ,,, BK PG g ❑ lam exem T under Sec. of the L.A.Co. STATE LICCL \ ` �\/ O P LICENSE NO. CLASS v T Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK E FINAL V U HOUSE SEWER CONNECTING TO DATE VALIDATION Las B. & P. Code for the following reason PUBLIC SEWER SEPTIC TANK,SEEPAGE PIT OR FI AL g Date PITS AND/OR DRAINFIELD HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR O NER-BUILDE DEC ARA WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE 10 Law for the following reason (Secton 7031.5, BUisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM 60 ..... A :CT o g ❑ I,as owner of the property,or my employees with wages as �� � �1.cl their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business �� C� and Professions Code). OWNERS Permit g J' <3 ❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE J, TOTAL 21- 50 licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO CASH Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLIN TO THE PUBLIC SEWER. CASH 21.50 CONSTRUCTION LENDING AGENCY g��:l � �' ► CHANGE o0Q I hereby affirm That there is a construction lending agency SIGNED DAY OF 19_ for the performance of the work for which this permit is OWNER A issued (Sec. 3097, Civ. C.). OWNERS AG Lender's Name ADDRESS 0000-0001 7/28/89 Lender's Address 4r3 1 AM11:20 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 this County to enter upon the above-mentio ed property for inspection purposes. S' nature of PJrmitt6e Date SEE REVERSE FOR EXPLANATORY LANGUAGE 1