HomeMy Public PortalAbout10161 LOWER AZUSA RD_Sewer__ WORKERS}COMPE14SATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or 76A642D LS
a certified copy thereof (Sec. 3800, Lab C.) CE 808(REV.8/81) APPLICATION FOR PERMIT
Policy/No_ Company OS SEWER - SEWAGE DISPOSAL
❑:Certified copy is hereby furnished.
,
Certified co y is fil qtzkbe county,building inspections/' COUNTY OF LOS ANGELES BUILDING AND SAFETY
Dat Applicant 10W/40L�-s4� � 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 LOCALITY MANHOLE REFERENCE LOWER
permit is for one hundred dollars ($100)or less.)
I certify that In the performance of-the work for which this CROSS SST. TYPE OF CONNECTION LENGTH FROM
Y. CURB P.L, M.L.TO P.L.
permit is issued, I shall not employ any person in any manner BALDW IN AVE.
so as to become subject to the Workers' Compensation Laws. P.C.NO.
I P OWNER CO.IMP.NO. JOB NO.
N`A'IL TRUNK PERMIT NO. ROAD PERMIT NO.
.Date-Applicant ADDRESS
NOTICE TO APPLICANT: If, after makin this Certificate Of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
g CITY TEL.NO. '
Exemption, you should become subject to the Workers'. LEGAL
80
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 PERMIT No.
LOT
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 full force and
CONNECTION CHARGE FEE
effect. /j�T-•/ CONTRACTOR �
License Number , /1/ 9 /_, ic.Class, ADDRESS NATIONAL SECURITY CONSTRUCT I O REIMBURSEMENT FEE
n � DISTRICT NO. GROUP MAP PROCESSED BY
Contra CtOr /��// ��,"'����""I U to CITY TELROSEMEAD .NO. _ JJJ��� BK PG
�a STATE L 0 / �
-,%
, i am exempt under Sec. o the L. CO. LICENSE NO. 471713 CLASS &--) f`P_,
Plumbing Code and/or Sec. of The NO. DESCRIPTION OF WORK .V FINAL Ny
_ HOUSE SEWER CONNECTING TO DATE 7 VALIDATION 0.
*3. & P. Code for the following reason ' PUBLIC SEWER J !✓
SEPTIC TANK,SEEPAGE PIT OR FINA
PITS AND/OR DRAINFIELD o
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
,•
I hOVERFLOW SEEPAGE PIT,DRAINFIELD
ereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE QrL
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE d{J
fessions Code): SEWER OR DISPOSAL SYSTEM b
v8
:❑ I,as owner of the property,or my employees with wages as r�
their sole compensation, will do the work and the structure 7.,. :. `7a5
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permit $- I ITFA
❑ I, Os Owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE • TOTS,. 27.50
Licensed COnirOClOfS TO construct the project (Section 7044; HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO f�{,�/t�/
Business and Professions Code). CONNECT THE ABOVE DESCRIB EXISTING DWELLING O THE PUBLIC SEWER. W A ICK 27.50
CONSTRUCTION LENDING AGENCY -7
00
I hereby affirm that there is a construction lending agency SIGNED THIS v Y OF 19=1 , •
OWNER OR -��RV Y #A 1 ROSE
for the performance of the work for which this permit i5 OWNERS AGENT Y
issued (Sec. 3097, Civ. C.). ��'yy�(yy�//�'�� �p
ADDRESS 5�25�07
Lender's Name
Lender's Address I MUM
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 lating Plumbi and Sewers,
and her y auth ize rep es tativ of this ounty to ter
upon t e above entio d er'�for inspe ion pure S.
Sig ature of Permittee DaIg SEE REVERSE FOR EXPLANATORY LANGUAGE