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HomeMy Public PortalAbout10169 LOWER AZUSA RD_Sewer__ -WORKERS'COMPENSATION DECLARATION I hereby affirm that (•-have a certificate of consent to self in or a certificate of Workers'Compensation Insurance, or 76A642D a certified copy thereof (Sec. 3800, Lab C.) EBDB(REV.8/81) APPLICATION FOR PERMIT Policy'No. Company ©s ❑T Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL •Certified copy is filed with the county building.inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY d; artment. DateVJ '"X�Applicontil/�'T� /, /ZM FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING COMPENSATION INSURANCE ADDRESS STATION DEPTH (This section need not be completed if the work involved by the UPPER permit is for one hundred dollars ($100)or less.) LocALiTv MANHOLE REFERENCE LOWER NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST. Y. CURB P.L. M.L.TO P.L. permit is issued, I shall not employ any person in any manner BALDW IN AVE. P.C.No. so as to become subject to the Workers'Compensation Laws. Ow ER co.IMP.No. JOB NO. MAII TEMPLERQLEXX NVESTMENT TRUNK PERMIT NO. ROAD PERMIT NO. Dpte� Applicant ADDRESS 8819 9. GARVEY ROS EMEAD p AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL, �818)288- 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 DECLARATIONNO.OF BLDGS. PERMIT No. I hereby affirm that I am licensed under provisions of ChSIZE OF LOT NOW ON LOTapter USE OF SINGLE FAMILY HOUSE 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. / CONTRACTOR O L• ITY col CONNECTION CHARGE FEE License Number / Lic.Class 6/L7) ADDRESS AD REIMBURSEMENT FEE g7?o/vfl SZ�iGLt2(7� O P tl Contractor l'GT � Date DISTRICT NO. GROUP MAP PROCESSED BY - CITY TEL.NO. - C. ��!!'�� BK PG a ❑ 4 am exempt under Sec. of the L.A.Co. STATE ENSE NO. LIL S �J 3 f O NO. DESCRIPTION OF WORK - E of Plumbing Code and/or Sec. of the FINAL VALIDATION HOUSE SEWER CONNECTING TO - DATE B. & P. Code for the following reason PUBLIC SEWER tsi _ SEPTIC TANK,SEEPAGE PIT OR FINAL g • PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR 7 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,MAN Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,RRQgiR1®A ND fesslons Code): - SEWER - ❑ I,as owner of the property, or my employees with wages as ACCT �} their sole compensation, will do the work and the structure 'r t�o, is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S Permit $. /J : 1 YS AUTHORIZATION TOTAL 27® 0 . ❑ I, as owner of The property, am exclusively contracting With TOTAL FEE licensed contractors to construct the project Section 7044; P I (, HAVE AT THIS DATE E CONTRACT WITH THE HEREIN NAMED CON RER. TO CWC 20.50 BUSIne55 and Professions Code). � CONNECT THE ABOVE�RIBED EXISTING DWELLING TO THE PUBLIC SEWER. - 7 CONSTRUCTION LENDING AGENCY ply I hereby affirm that there is a construction lending agency SIGNED THIS DAY — v 19_ ► .00 for the performance of the work for which this permit' is OWNER OR OWNERS AGE _ - .,.. „• . . . sued (Sec. 3097, CIV. C.). ADDRESS „I.iW1 5 25/89 Lender's Name _ 6177 Lender's Address - ' 3549 1 A111:54 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 Sto laws regulating Plumbing and Sewers, and hereby outh ze represe tatives of this County to enter up o the ab ve- oned pr erty for in ection�urposesd A A,7 . . - - nature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE