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Home My Public Portal About9921 LOWER AZUSA RD_Sewer__ WORKERS'COMPENSATION DECLARATION 1 hereby c#firm that I have a certificate of consent to self insurg, or a certificate of Workers'Compensation Insurance,or 76Ae42D a certified cap thereof(Sec. 3800, Lab C.) 620002 DPW 6/88 APPLICATION FOR PERMIT Policy No. "—Company a Certifiehi copy is hereby furnished. V� SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. ' Date `411 Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING qq 21 ��b COMPENSATION INSURANCE ADDRESS 69— • STATIdJ DEPTH (This section need not be completed if the work involved by the LOCALITY ••�KPL.� t.�i U PPE e permit is for one hundred doljgrs(x100)or less.) NEAREST ��} TYPE OFOONNECTION tENGTI�FROM a 1 certify that in the performance of the work for which this CROSS ST. V�w A Y. CURB P.L. M.L.TO P.L. permit is issued, I shall not employ any person in any manner Q�cc G��•r so as to become subject to the Workers'Compensation Laws. OWNER M N • • N CO.IMP.NO. Joe NO. MAIL ■1TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS • /II NOTICE TO APPLICANT: If, after making this Certificate of CITY L NO • AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE Exemption, you should become subject to the Workers' Compensation provisions of the Labor code,you must forthwith _ DESCRIPTA IO /�N LOT NO. (.- HWY.OR ST WIDENING comply with such provisions or this permit shall be deemed revoked. BLOCK TRACT 0 STATE ENCROACHMENT NO.OF BLDGS. ,r PERMIT NO. _ LICENSED CONTRACTORS DECLARATION SIZE OF LOT S•19•Now ON Lor UW TTS I hereby affirm that I am licensed under provisions of Chapter +� 9 (commencing with Section 7000) of Division 3 of the Busi- USE EiDINGs 1 •5'��► A aIARGEs ness and Professions Code, and my license is in full force and � effect. ' CONTRACTOR M 1� ^ 7 T� Cftt,��t)W ! , CONNECTION CHARGE.FEE p License Numbe I �Lic.Class} ADDRESS • AS REIMBURSEMENT FEE COniraClar �r/L'r`+.ar Date "/�� •?1 CITY �� TEL.NO t DISTRICT NO. GROUP BK MAP PROCESSED BY TATE UC. , �,�8 .3 ❑ I am exempt under Sec. of the L.A.Co. LICENSE NO.* UCLAW C. Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL HOUSE SEWER CONNECTING TO DATE VALIDATION 'rn B. 8 P. Code for the following reason PUBLIC SEWER Z SEPTIC TANK SEEPAGE PIT OR PITS E SEWS t DR CONNECTING FINAL Ell ,r Date HOUSE SEWER CONNECTING TO BYC��'/i Signature ! U i/OILJ CONNEPRIVATE D SYSTEM . CONNECT ADDITIONAL BLDG.OR ► WNER-BUILDER DECLARATION WORK TO HOUSE SEWER .OVERFLOW SEEPAGE PIT DRAINFIELD I hereby affirm that I am exempt from the Contractor's License EXTN. CESSPOOL DRYI U.,-MANHOLE Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE 10 fessionS Code): SEWER OR DISPOSAL SYSTEM ❑ I,as owner of the property,or my employees with wages as ' Ttl•4 I o F their sole compensation,will do the work and the structure -7-07 -4. is not intended or offered for sole (Section 7044, BusinessZf and Professions Code). OWNER'S Permit E ,� 1 ITENS ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO TOTAL 34 m 51D Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY pa ��E�Yi 3 4.5f l_ SIGNED THIS � DAY OF ® 19— I hereby affirm that there is a construction lending agency CHIME X00 OWNE for the performance of the work for which this permit is OWNER OR k1ft LA 0— issued (Sec. 3097, Civ. C.). ADD,SSDDRESS AGENT A �� Lender's Name 1 2/ 7/?1 Lender's Address cr 1 AN S 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 regulating Plumbing and-Sewers, and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE