HomeMy Public PortalAbout9646 LONGDEN AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate 'of consent to self jl
insure, or a certificate of Workers'Compensation Insurance, or 76Ae42o U
a certific�d copy thereoff (Sec. 3800, Lab C., b° IREV „�:;; APPLICATION FOR PERMIT
Policy l�io.''���-�Y1"`�ompany �3�ur�s��fi -Tr✓� •.f~
El 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.
Dote r�i c Applicant r� � I—, _ FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' [NEAREST
IR oI IN �' .% ,y <` STATION DEPTH
COMPENSATION INSURANCEIlk
(This section need not be completed if the work involved by the CALITY �%G,6 MANHOLE REFERENCE UPPER
OWER
permit is for one hundred dollars ($100)or less.)
I certify that in the performance of the work for Which this j TYPE OF CONNECTION LENGTH FROMy p OSS ST Cay G �IC�l • V. CURB P l MA TOPL
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. OWNER "yam P.C.NO.
�-�� � �" CO IMP.NO JOB NO.
MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS 3 Gi:
AFFIDAVIT WAIVER EASEMENT RECORD.INSTR,NO. DATE
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL.NO. �s-i�s�
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 f �}
I hereby affirm that I am licensed under provisions of Chapter USE ofdU" c fd
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. J CONTRACTOR CONNECTION CHARGE FEE
License Number T ',O Lic.Class ,es ADDRESS 3? '.L: REIMBURSEMENT FEE
Contractor C.-✓� �--�'F'� Date >=�/ '�> y DISTRICT NO. GROUP MAP PROCESS�D BY 0
CITY TEL.NO. ``_ BK PO t��% V
❑ I am exempt under Sec. of the L_A.Co. LICENSE NO CLTATE ASS J cA f� 09
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE 0 FINAL H
HOUSE SEWER CONNECTING TO 6'1/s DATE s VALIDAT) iN V
PUBLIC SEWER Pf(f
B. & P. Code for the following reason C W
SEPTIC TANK,SEEPAGE PIT OR
PITS ANDiOR DRAINFIELD FIN S H
Date HOUSE SEWER CONNECTING TO B Z
PRIVATE DISPOSAL SYSTEM >
Signature CONNECT ADDITIONAL BLDG.OR '
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
1 I hereby affirm that 1 am exempt from the Contractor's License OVERFLOW SEEPAGE PIT,DRAINFIELDEXTN.,CESSPOOL,DRYWELL,MANHOLE c
" Law for the following reason (Secton 7031.5, BUisness and Pro- ALTER,REPAIR OR ABANDON HOUSE i9,55tit 3,4 A,
SEWER OR DISPOSAL SYSTEM
fessions Code): # • • • • 1
G
❑ 1, as owner of the property,or my employees with wages as • + (i ��
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNERS Permit $ 5 + • • 4 4,5 G 7
❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE ® �rl d 22—
85
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CO TRACTOR TO
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY �J f p ��� �.� C ►
I hereby affirm that there is a construction lending agency SIGNED THIS i
"�-
OWNER OR
for the performance of the work for which this permit is OWNERS AGC '""
issued (Sec. 3097, Civ. C.). ,b
�.. ADDRESS
Lender's Name !F '
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 authorizer resentatives of this County to enter
upon the above-menDP`o"d— operty for inspection purposes.
ignature of Ri4rmiitee _ Date ri r -g s, SEE REVERSE FOR EXPLANATORY LANGUAGE
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