HomeMy Public PortalAbout9923 LOWER AZUSA RD_Sewer__ - WORKERS'COMPENSATION DECLARATION r
I ?Lereliy affirm that 1 have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or 76AS42D
a certified copy thereof(Sec. 3800, Lab C.) 92.0002 DPWS/W APPLICATION -FOR PERMIT
Policy No. Company "n" no SEWER - SEWAGE DISPOSAL
Certifl copy is hereby furnish
❑ Certified copy is filed with,the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
DOIXde rtment.
Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPT N FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDRESS Q AZtI • STATION DEPTH
(This section need not be completed if the work involved by the LacALITYI L�{7 at MANHOLE REFERENCE UPPER
permit is for one hundred dollars($100)or less.) � "r�
OWER
I cern that in the performance of the work for which this �5T. A • TYPE OF�N�� LENGTH FROM
P Y. CURB P.L. M.L.TO P.L.
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. OWNER M • 6— a CO.IMP.NO. P.C.ANO.
` ,i
MAIL
AII KESS E• fZV -MMAS Oto TRUNK PERMIT,NO. ,ROAD PERMIT NO.
Date Applicant
NOTICE TO APPLICANT:_ If, after making this Certificate of CITY � Qg#jV Ae ♦114p AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
Exemption, you should become subject to ,the Workers' 1✓-1 1 r Tr'
Compensation provisions of the Labor code,you must forthwith DESCRIPTION IPTION LOTNO. LIZ ' I$
comply with such provisions or this permit shall be deemed HWY.OR ST.WIDENING
revoked. BLOCK TRACT 9A413 STATE ENCROACHMENT -
LICENSED CONTRACTORS DECLARATION NO.Of BLDGS. PERMIT NO.
1 hereby affirm that I am licensed under provisions of Chapter SIZE of LOT 2�.Q``{.V� �''�.Now ON LOT
9 (commencing with Section 7000) of Division 3 of the Buse- BBUILDINGS $ZpaJfe. AL- CHARGES
ness and Professions Code, and my license'is in full force and
effect. ^ CONMCrOR I CONNECTION CHARGE FEE R
License Number 1 Lic.Class ASS • REIMBURSEMENT FEE v
Contractor M I Date Z' ! ' q' CITY ZOO Cil L.NO. ,a •112140
DISTRICT NoY GROUP 8K MAP PG PROCESSED BY �.
❑ I am exempt under Secof the L.A.Co. STATE LICENSE NO. U
CLASS 444JJJ
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL VALIDATION cn
HOUSE SEWER CONNECTING TO , DATE /,, _
B. 8 P. Code for the following reason PUBLIC SEWER `�� Z
SEPTIC TANK SEEPAGE PIT OR
PETS AND/Olt DRAINFIELD FINAL
Date HOUSE SEWER CONNECTING TO BY L
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR
NER-BUILDER DECLARATION WORK TO HOUSE SEWER
I hereby affirm that I am exempt from the Contractor's License IELD
EXTN.OVERFLOWs ooi,DRYWELL,l�NnrNHOLE
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR A&4NDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM ACCT3
.B
❑ I,as owner of the property,or my employees with wages as 3307 _154i.50
their sole compensation,will do the work and the structure 1 �,
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permit S
El 1,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE TOTAL 34 -50
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONT R TO CECK .34.50 •
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY ► CHANE •[I(i
I hereby affirm that there is a construction lending agency SIGNED THIS �DAYOF_8yLbY.t •y 19�1
for the performance of the work for which this permit is OWNER OR
issued (Sec. 3097, Civ. C.). OWNeas AGENT 7.
„amu N ObOO-0001 2/ 7/91
Lender's Name 5525 1, AM
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
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