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HomeMy Public PortalAbout10213 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 lacy,o:copy thereof (Sec. 3800, Lab C.) 92-0002 DPW 6/88 APPLICATION FOR PERMIT PolicyNo� Company ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDINGL �y COMPENSATION INSURANCE ADDRESS STATION DEPTH© T 2S i (This section need not be completed if the work involved by theLOCALITY / / MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) v tse I certifythat in the performance Of the Work for which this NEAREST TYPE OF CONNECTION LENGTH FROM P CROSS ST. O Y. CURB P.L. M., TO P.L. permit is issued, I shall not employ any person in any manner P.C.NO. so as to become subject to the Workers'Compensation Law OWNER MMIA CO.IMP.NO. JOB NO. MAIL TRUNK PERMIT NO. ROAD PERMIT NO. Dat App l i ca nt ADDRESS yrs �g AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTICE TO APPLICANT: If, after making this Certificate of CIT ,% EL.NO.j 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 am licensed under provisions of Chapter uSE OF 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS I CHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTOR p CONNECTION CHARGE FEE License Numbe " ��0_qj(' Llc.Class ­ (/�� ADDRESS �y/ I �/ REIMBURSEMENT FEE COntractor�a/,/ Y/ Date � 7 / CITY T .NO. Y��r " DISTRICT NO. GROUP BK MAP PROCESSED BY STATE UC. C, g ❑ I am exempt under Sec. _of the L.A.Co. LICENSE No. �� IA `/) vo L f/JwJ_✓L� Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL HOUSE SEWER CONNECTING TODATE VALIDATION PUBLIC SEWER g4Ti B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD FINAL o Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR , OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER I hereby affirm that I am exempt from the Contractor's License EO TN.,OW CESSPOOLEGDR IYWELLAIINFIELD MANHOLE Law for the following reason (Secton 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 their sole compensation, will do the work and the structure i?1 is not intended or offered for sale (Section 7044, Business s and Professions Code). OWNER'S Permit $ 3 Q f7 `3L•_;.•Tos ❑ I,as owner of the property,am exclusively contracting with AUTHORIZAT ON I TOTAL FEE 13 1_3307 -34.5,1% licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS D E A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO yy —1-:�� Business and Professions Code). CONNECT THE AB E ESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. 1 I={+,.� CONSTRUCTION LENDING AGENCY �7 /) / •r TAI 34 = 50 I hereby affirm that there. is a construction lending agency SIGNED THIS / Y OF —14U €I hLL —ter' for the performance of the work for which this permit is OWNER OR / t - C"j �,, =L11 OWNERS AGE ` `_i")trC :.-r,•_,: issued (Seq. 3097, Civ. C.). + ADDRESS : .;-� �`,;�;M Lende s Name Len er's A dress 1 rtify tat I have read this application and state that the a Ove ormation ' orrect. I agree to comply with all County ry7.� h14` in es and St to ws reguI ng Plumbing and Sewers, wt�t;J rf.i j l F� ._ nd eby author ze present fives of this County to enter e bo men' pr a for inspection purposes. rr SignaZt f mit ee Date SEE REVERSE FOR EXPLANATORY LANGUAGE