HomeMy Public PortalAbout9509-9513 LONGDEN AVE_Sewer__ WORKERS' CQMPEN5ATION DECLARATION
I hereby affirm that 1 have a certificote of consent to self jI
9nsure, or certificate of Workers'Compensation Insurance, or �aAba2o U
a certified copy �reof (Sec. 3800, La , _�-�/ CE608(REY 1,831 APPLICATION FOR PERMIT
Policy No.'- AA G" Company �✓-19- a �1,
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
❑ Certified copy is filed with the county buildi g ection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
DateA-4 =d: � Applicant t " FO P I NT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXE ' ION FROM WORKERS' BUILDING
COMPENSA ION INSURANCE ADDRESS _�-� it ' P �G�e STATION �j DEPTH
(This section need not be completed if the work involved by the LOCALITY /E� f �� r MANHOLE REFEERRENC .5 �g I 14
CCC666 "uPP ER
permit is for one hundred dollars ($100)or less.)
I certify that in the performance of the work for which this CROSSSST. ��7r 4 TYPE OF CO N LENGTH FROM
`3- � V. CURB P.L. M .TO P L.
permit is issued, I shall not employ any person in any manner PC.NO.
so as to become subject to the Workers'Compensation Laws, OWNER 19 k 1� Pe yew° 1 k s CO IMP,NO. JOB NO.
NAIL ��t�''--qq TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS e-
-Applicant 0 r
% AFFIDAVIT
/` WAIVER EASEMENT RECORD INSTR.NO. DATE
NOTICE TO APPLICANT: If, after making this Certificate of CITY{�,4 il'-feW f�64 L.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 1 1 7,6 Al
LICENSED CONTRACTORS DECLARATION �f/ d��� No of BLDGS PERMIT NO.
SIZE OF LOT (cam�J.�, "LJ 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 -3r CHARGES
ness and Professions Code, and my license is in full force and
CONNECTION CHARGE FEE
effect. CONTRACTOR
License Number Lic.Class ADDRESS tryii REIMBURSEMENT FEE }
TEL.NO. - ��} DISTRICT NO. GROUP MAP PROCESSE¢BY Q
Contractor Date CITY
Y4&3 SK PG N[>'
U
(�' �s
❑ 1 am exempt under Sec, of the L.A. Co. LICENSE NO F G ' CLASSF 5�
NO. DESCRIPTION OF WORK FEE O
E
Plumbing Code and/or Sec. of the HOUSE SEWER CONNECTING TO / �+y^ DA FINAL e/ -l� VALIDATIO U
PUBLIC SEWER f F s'+.- _-
B. 8 P. Code for the following reason �J W
SEPTIC TANK,SEEPAGE PIT ORa.
PITS AND/OR DRAINFIELD V
Date HOUSE SEWER CONNECTING TO f ` /: Z
PRIVATE DISPOSAL SYSTEM f _
Signature CONNECT ADDITIONAL BLDG.OR 41
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 N
Law for the following reason (Secton 7031.5, BUisness and Pro- ALTER,REPAIR OR ABANDON HOUSE +� �.
fessions Code): SEWER OR DISPOS L SYSTEM -
❑ I,as owner of the property,or my employees with wages as �
• • s • V
their sole compensation, will do the work and the structure ) •
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permit $ n • o • 'J 8, 5 ()v
❑ 1,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 NAM TRACTOR TO 10,25-85
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO 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 OR
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
ordinances and State laws regulating Plumbing and Sewers,
and hereby authoriz r esentatives of this County to enter
upon th above-me ti d property for inspection purposes.
ignature of er ittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE