HomeMy Public PortalAbout9363 LOWER AZUSA RD_Sewer__ WORXERS'COMPENSATION DECLARATION
'T hereby?affirm thot d have a certificate of consent to self
Insure, or a certitcate of Workers'Compensation insurance, or 76A642D
` a certified copy thereof(Sec. 3800, Lob C.� 92-0002 DPW 8/85 APPLICATION FOR PER
Policy No. Company
Y ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
L-1Certifiedcopy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING D SAFETY
department.
Date_ App!;cont: _y FOR APPLICANT TO FILL IN CO ECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDRESS Jf7` J STATION DEPTH
(This section need not be completed if the work involved by theLQCAl1TY (� gyp. ✓ MANHOLE REFERENCE UPPER
OWER
permit is for one hundred dollars ($100)or less,)
NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. ? Y. CURB P L Mt TO P.L.
permit is issued, I shall not employ any person in any manner
so as to become sub ect to the Workers'Com ensation Laws- r+ � %'�f+'- P.C.NO.
OWNER CO.I p / IMP.NO. JOB NO.
MAIL
C .f'�' TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant f C �-V/ -d i��! ADDRESS
i AFFIDAVIT WAIVER EASI k7ORD.INSTR NO. DATE
NOTICE TO APPLICANT: If, after making this Certificate of CITY / cj/ L.NO.
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. F LOT r 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 t CHARGES
ness and Professions Code, and my license is in full force and r
effect. _ CONTRACTOR �r ,. �— CONNECTION CHARGE FEE
LicenseNu
///� Lic.Class_/S — ADDRESS �9 REIMBURSEMENT FEE
Y_ ,- *
ContraCt -� Date DISTRICT NO. GROUP MAP PROCESSED BY
l CITY TEL.NO, C. SK PG
❑ I am exempt under Sec. _of the L.A.Co. LICErEiSE NO. Z f CLASS
Plumbing Code and/or Sec. of the NO. DES R PTI N OF WOK FEE PINAL44 ww,
HOUSE SEWER CONNECTING TO ~}
B. & P. Code for the following reason PUBLIC SEWER { DATE V 4 VAL ATI
SEPTIC TANK,SEEPAGE PIT OR v
PRFINAL
S AND/OR DRAINFIELD I"
Date HOUSE SEWER CONNECTING TO BY r
PRIVATE DISPOSAL SYSTEM _
u;
Signature CONNECT ADDITIONAL BLDG.OR
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
Low for the following reason (Secton 7031.5, BUisness and Pro- ALTER,REPAIR OR ABANDON HOUSE = °
fesslons Code): SEWER OR DISPOSAL SYSTEM
❑ I,as owner of the property,or my employees with wages as
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNERS Permit $ `� j NE
❑ I,os owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE -i 34;.. ¢
licensed contractors to construct the project (Section 7044, t HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO [; „
Business and Professions Code). CONNECT THE ABOVE DE E EXISTING DWELLING TO THE PUBLIC SEWER. ivrt HE r5
CONSTRUCTION LENDING AGENCY
I hereby affirm That there is a consirudion lending agency SIGNED THIS DAY 19( � tK°i- _==1
PV
for the performance of the work for which this permit is OWNER
OWNERS AGENT FJ --
issued (Sec. 3097, Civ. C.).
ADDRESS
Lender's Name_ ^'
lender`s Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinanc s and State laws regulating Plumbing and Sewers,
and y authorize representatives of this County to enter
upo th aboven ned property for inspection purpos
r ;
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE