HomeMy Public PortalAbout9648 LONGDEN AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to self {I'
insure, or a certificate of Workers'Compensation Insurance, or 76A642D U
,ayeytt3fe �pythreof (Sec. 3$00, La�C.) f,�? CE90sIREY ,,a3 APPLICATION FOR PERMIT
rolicy No. Company xl�"�� e �� *`
❑ Certified copyishereby furnished. SEWER - SEWAGE DISPOSAL
® Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Date ,4 e';'Applicant � ' a FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION DEPTH
COMPENSATION INSURANCE ' ADDRESS .?
(This section need not be completed if the work involved by the -- �j MANHOLE REFERENCE UPPER
LOCALITY /'� �'
permit is for one hundred dollars ($100)or less.) LOWER�,....y.�-• LENGTH FROM
I certifythat in the performance of the work for which this NEAREST /C.-�Ir TYPE OF CONNECTION
P CROSS ST. �C`� i �"'j� Y. CURB P.L M.L.TO P.L,
permit is issued, I shall not employ any person in any manner P.0 NO
so as to become subject to the Workers' Compensation Laws. OWNER r CO.IMP,NO. JOB NO
MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS r �l f EAG.
AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL.NO. = . -"�3So
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 s 2-0//
1 hereby affirm that I am licensed under provisions of Chapter USE OF
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 yp
effect. CONTRACTOR f. � �,,. �.GI"7..5✓ CONNECTION CHARGE FEE
y' ADDRESS `,may _ rREIMBURSEMENT FEE a
License Number•, r Lic.Class
Contractor Date . -c: '`' " DISTRICT NO. GROUP MAP PR ESSED BY 0
CITY TEL NO. BK PG
❑ I am exempt under Sec. of the L.A.Co. STATE LLC //) 3 �
p LICENSE NO. CLASS st V Q
O
Plumbing Code and/or Sec. of the NO. DESCRIPTION F WORK FEE F"'FINAL V
HOUSE SEWER CONNECTING TO DATE
PUBLIC SEWER 00 VALID , ION LU
B. 8 P. Code for the following reason y
SEPTIC TANK,SEEPAGE PIT OR FINAL
PITS AND/OR DRAINFIELD Z
Date BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR ,
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWERE PIT, f
I hereby affirm that I am exempt from the Contractor's License EO TNFLOC SSPEOOLEPAGDRYWEDLRLAMANHOLE f/ 3 5 35 A
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE f
fessions Code): SEWER OR DISPOSAL SYSTEM 0 A ® q 0
El 1, as owner of the property, or my employees with wages as 1
their sole compensation, will do the work and the structure e ® � 4,5 b
is not intended or offered for sale (Section 7044, Business
and Professions Code), OWNER'S Permit 1CONTRACTOR
{} s e 4 4, 5 0 v
❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE 1
licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREINTO f G 2-!-8 5
r Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TOCONSTRUCTION LENDING AGENCY -7-- ,I hereby affirm that there is a construction lending agency SIGNED THIS �.r- DAfor the performance of the work for which this permit is OWNERSWNER Oissued (Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
Lender's Address z' "
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 rep 4mentotives of this County to enter
Upon the above-mentip4fed✓f7f erty for inspection purposes.
r _
r ignature of Permitt a ;mate SEE REVERSE FOR EXPLANATORY LANGUAGE