HomeMy Public PortalAbout9453 LONGDEN AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that 1 have a certificate of consent to self
insure, or a tertificate of Workers'Compensation Insurance, or "ASQD
a Certified copy thereof (Sec. 3800, Lab C.) ' Q2-W02 DPW 6/86 . APPLICATION FOR PERMIT �I
Policy No._?, ' Company 1
❑ 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
COMPENSATION INSURANCE ADDRESS STATIQN DEPTH
( completed e workinvolved by
this section need not be com ld if the the UPPER
permit is for one hundred dollars ($100)Or I@S5.) iQCALITV MANHOIf REFERENCE (OWER
NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. Y. CURB P.I. M.L.TO P1,
permit is issued, I shall not employ any person in any manner
so as to becomeP subject to the Workers'Compensation LAWS. JWNER CO.IMP.NO. P C Na.
NO.
MAIL
Date Applicant ADDRESS TRUNK.PERMIT NO. ROAD PERMIT NO.
3 -, -
NOTICE TO APPLICANT: If, after making cae oC!TV '
this Certificate i" AFFIDAVIT WAIVER EASEMENT RECORD.IN! NO DATE
- TEL..NO.
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 BLDGS. PERMIT NO.
SIZE OF LOT NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter TSE OF
9 (commencing with Section 7000) of Division 3 of the Bus I- BUILDINGS CHARGES
ness and Professions Code, and my license is in full force and
effecf•,: CONTRACTOR CONNECTION CHARGE FEE
Licenv!Number Lic.Class ADDRESS REIMBURSEMENT FEE
Contractor Date DISTRICT GR UP MAP CKESSED Y
CITY TEL.NO. �r"® SK PG
❑ I am exempt under Sec. ATE LIC.
—Of the L.A.Co. a CENSE NO. CA55 �'rl � , � F"°i U,
W
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL VALIDATION N
- HOUSE SEWER CONNECTING TO ��? DATE
B. & P. Code for the following reason y; PUBLIC SEWER �, Z
SEPTIC TANK,SEEPAGE PI OR FINAL
PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signutur@ 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
Law for the following reason (Secton 7031.5, BUisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM
�} 1,as CWner of the property,or my employees with wages as
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business i�Jtifl� '
and Professions Code). OWNER'S Permit $ i' -`�
❑ 1,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE
licensed contractors to construct the project (Section 7044, HAVE AT THIS GATE A CONTRACT WITH THE HEREIN NAMED CONT ACTOR TO I` 0 a "} �3 'RC1
BVSInD55 and ProfeSSIOr1S Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. ';1. J'y
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_ 4s
for The performance of the work for which this permit is OWNER OR
eWrvERS AGENT
issued (Sec. 3097, Civ. C.).
Lenders Name ADDRESS
Lender's Address Ai; xF
1 certify that I have read is application and state that the p`
rxaCve 'nformatton is correct. I ogre o amply with all County
ordin b and St e I s r gul in Plumbing and Sewers,
and r by,auth 1z ep ti v s this County to enter
upo ove- e(n on y f inspection purposes.
Signature 0 P rmitte Date SEE REVERSE FOR EXPLANATORY LANGUAGE