HomeMy Public PortalAbout9650 LONGDEN AVE_Sewer__ WORKERS' COMPENSATION DECLARATION
I hereby off rm that I have a certificate'of consent to self jl
insure, or a certificate of Workers'•Compensation Insurance, or ,__76A642D U
`ce epyth eof (Sec. 3800,.��C.) cEaoe!REv.vaa' APPLICATION FOR PERMIT
Pollc�o. � Compan��.�"t"/�r �.- ���' •' _.,.
El Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
"'tf Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department. "
Date/ter "Applicant �' "" FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS BUILDING STATION DEPTH
COMPENSATION INSURANCE ADDRESS rJ
(This section need not be completed if the work involved by the //c9 r� MANHOLE REFERENCE UPPER
permit is for one hundred dollars($100)or less.) LOCALITY /C ✓aJ yam, LOWER
I certifythat in the performance Of the work for which this NEAREST --tT / TYPE Of CONNECTION LENGTH FROM
P CROSS ST. f Y. CURB P,I. M.L.TO P.L.
permit is issued, I shall not employ any person in any mannerP.C.NO
so as to become subject to the Workers' Compensation Laws. OWNER C
CO IMP NO. JOB NO.
MAIL r s TRUNK PERMIT NO, ROAD PERMIT NO.
Date Applicant ADDRESS �iJ ,✓{7
_ ;77
FFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL.NO. ��CQS ��
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 Om licensed under provisions of Chapter USE OF S` f�
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES
ness and Professions Code, and my license is in"p full force and
effect. e" ��2 CONTRACTOR I ' f ♦ ,� CONNECTION CHARGE FEE
License Numbetr✓ 1�L Lic.Clos9b'ti�=s �r---- ADDRESS T i/� REIMBURSEMENT FEE
Contractor !/'" Dote / �r f 0 J DISTRICT NO. GROUP MAP P OCESSEO BY 0
CITY TEL NO ,r t} BK PG V
❑ I am exempt under Sec. of the L.A.Co. STATE CLLIC !Vk K IILLrr
p LICENSE NO. CLASS E OL
NO. DESCRIPTION OF WORK FEE } VALIDA {ON V
Plumbing Code and/or Sec. of the FINAL
- HOUSE SEWER CONNECTING TO / DATE . W
B. & P. Code for the following reason PUBLIC SEWER i.
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR DRAINFIELD FINAL 9LN
Date HOUSE SEWER CONNECTING TO BY / Z
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR ,
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
1 hereby affirm that I am exempt from the Contractor's License OVERFLOW SEEPAGE PIT,DRAINFIELDEXTN,CESSPOOL,DRYWELL,MANHOLE
Law for the following reason (Sectors 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM ,
❑ 1, as owner of the property,or my employees with wages as J 4
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business Permit $ 1 • e 0 • 0
and Professions Code). OWNER'S _
❑ I, as Owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE j ► • * 4 k rjQ
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. • ' f�50'j
CONSTRUCTION LENDING AGENCY �y,r-�
SIGNED TH15 f' 0 /c 19 .. 2
I hereby affirm that there is a construction lending agency a ► c� G "cg
OWNER OR
for the performance of the work for which this permit IS OWNERS " '
issued (Sec. 3097, Civ. C.).
fes;
ADDRESS —
Lender's Name /
Lender's Address
I certify that I have read this application and state that the xw 1`�+ 's.l tz
above
tion is
th
ordinances ape State laws regulating ree to comply I
lot ng PI mb ng andl Co
unt
SewersY ?
c,
and hereby authorize representatives of this County to entera �n , $ t
upon the above-meivtianed-property for inspection purposes.
J Signature O�er tee - Date.� 7 SEE REVERSE FOR EXPLANATORY LANGUAGE