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HomeMy Public PortalAbout10159 LOWER AZUSA RD_Sewer__ WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance, or 76a642D a c�rTified copy thereof (Sec. 3800, Lab C.) EE BDB(REV.B/B,> APPLICATION FOR PERMIT Policy No. Company ©s ElCertified copy is hereby furnished. SEWER - SEWAGE DISPOSAL Certifierpdac�otp�y is�f lFd�with the county building inspection �y1.Y�) '✓ COUNTY OF LOS ANGELES BUILDING AND SAFETY Datdep t`�J"� -CA•p)p_llcant� � �� ` t / 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 InVOIVed by the LOCALITY MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.). NEAREST TYPE OF CONNECTION LENGTH FROM LOWER I certify that in the performance of the work for which this CROSS ST. Y. CURB P.I. M.L.TO P.L. permit is issued, I shall not employ any person in any manner BALDWIN so as to become subject to the Workers Compensation Laws. P.C.NO. I p OWNER CO.IMP.NO. JOB NO. MAIL TEMPLE ROLEXX INVEST TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS - AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTICE TO APPLICANT: If, after making this Certificate of CITY ROS EMEAD TEL.No. (818)288-1080 Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO.' A_STRUCTIO OR ST.WIDENING comply with such provisions or this permit shall be deemed revoked. BLOCK TRACT ENCROACHMENT NO-OF BLDGS. NO. LICENSED CONTRACTORS DECLARATION SIZE OF LOT NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter USE OF 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES ness and Professions Code, and my license is in II force and effect. i CONTRACTOR ECTION CHARGE FEE License Numbe�r�}y-/- `�Lic.Class '> 10 ADDRESS NATIONAL SECURITY COURSEMENT FEE I COnirOClor�!�' / 1" � _jF G GI ^G ICT NO. GROUP MAP PROCESSED BY CITY TELROSEMEAD .NO. BK PG❑ I am exem t under Sec. of the L.A.'Co. STATE L (P LICENSE NO. LAS$NO. DESC P I F WORplumbing Code and/or Sec. of the � VALIDATION HOUSE SEWER CONNECTING TO B. & P. Code for the following reason PUBLIC SEWERSEPTIC TANK,SEEPAGE PIT OR gPITS AND/OR DRAINFIELDDateHOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM Signature - CONNECT ADDITIONAL BLDG.OR - y" ,, 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 10 Law for the following reason (Secton 7031.5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE Y fessions Code): ~ SEWER OR DISPOSAL SYSTEM _ ACCT.AT❑ 1,as owner of the property,or my employees with wages as their sole compensation, will do.the work.and the structure 3307 27.50 is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S Permit $ 11� ❑ I, as owner of the property, am exclusively-contracting with AUTHORIZATION TOTAL FEE TOTS- 27.50 licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO J'.�j Business and Professions Code). CONNECT THE AB ESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CK 27.50 CONSTRUCTION LENDING AGENCY C7 .O� 1 hereby affirm that there is a construction lending agency SIGNED THISMIX D Y OF 19_ ► _. ......_. ...... for the performance of the work for which this permit is OWNER OR t issued (Sec. 3097, Civ. C.). OWNERS AGENT Lender's Name ADDRESS 0000-Ml 5/25/89 Lender's Address 3%6 1 AM11:52 I certify that I have read this application and state that the above information is correct. I. gree to comply with all County ordinances and State laws v gulatin Plumbing and Sewers, and �above 'ze rep entativ of thi County to enter uponntion propert for ins ction pur ses. I azure of Perm tee D e SEE REVERSEFOR EXPLANATORY LANGUAGE