HomeMy Public PortalAbout9925 LOWER AZUSA RD_Sewer__ WORKERS'COMPENSATION DECLARATION
I'hereby affirm that I have a certificate of consent to self
insure, o00r a cgrtificate of Workers'Compensation Insurance;or T61812D
a certified o thereof(Sec. 38 ,,Lob C.) 92-0002 DPW 6/88 APPLICATION FOR PERMIT
Policy'No. Company GON�I�A3d11EE�
❑ Certifie:coopy is hereby furnishl�As0�a10S f(MO 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' BUILDING ct Q� �W� w•A Iaa A n�• STATION DEPTH
COMPENSATION INSURANCE ADDRESS �nl �+� 1 !'•
(This section need not be completed,if the work involved by the LaeAUT M G MANHOLE REFERENCE U PPE e
permit is for one hundred dollars (:100)or less.)
1 certify, that in the performance of the-work for.which this NEAREST TYPE OF CONNRCtION LENGTH FROM
CROSS ST. �� • V. CURB P.L. M.L.TO P.L.
permit is issued, 1 shall not employ any person in any manner r� P c No
so as to become subject to the Workers'Compensation Laws. OAR M • IV a co,IMP.No, JOB NO.
MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDREsS 5 Q
NOTICE. TO APPLICANT: If, after making this Certificate of CITY sm ' .144& ' AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
Exemption, .you should.'become subject to the Workers' A
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 SIZE OF LOT g/1 d�G S NO.OF BLDGS. UMIfiS PERMIT No. 1
• • NOW ON LOT
1 hereby affirm that I am licensed under provisions of Chapter usE1
9 (commencing with,Section 7000) of Division 3 of the Busk BUILDINGS q CHARGES
ness and Professions Code, and my license is in full force and
effect. i I CONTRACTOR M I C�O I•�+'�• CONNECTION CHARGE FEE Q
License Number Lic.Classy �W M4 V
W
���/�� qpD�� REIMBURSEMENT FEE
Contractor ^'•I•' •V—H Date 2-1 -411 CIT, 6t�9R1G1. L No • DISTRICT NO. GROUP MAP - PROCESSED BY O
SK PG
❑ 1 am exempt under Sec. of the L.A.Co. LICENSE No CLASS t
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINALv `-i a
HOUSE SEWER CONNECTING TO DATE _aq_q.� VALIDATION
PUBLIC SEWER to
B. g P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR - Z
PITS AND/OR DRAINFIELD FINAL �,yF
• Date HOUSE SEWER CONNECTING TO BY
V' A ) PRIVATE DISYSTEM
Signature w✓ CONNECT ADDITIONAL BLDG.OR,. - polo '
WNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT GRAINFIELD
I hereby affirm that I am exempt from the Contractor's License EXTN. CESSPOOL DRYI�JELL,MANHOLE �I
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE 1Q
fessions Code): SEWER OR DISPOSAL SYSTEM
El 1,as owner of the property,or my employees with wages as ACCT.T
their sole compensation, will do the work and the structure 3307 34.50
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permit E 00 1 ITEHS
❑ 1,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE --,
licensed contractors to construct the project Section 7044, TOTAL 34 e 50
P I ( I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON ACTOR TO I
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CHECK LENDING AGENCY d,� , fTLI�(�
I hereby affirm that there is a construction lending agency SIGNED THISNT AY OF _19� CWGE 413
for the performance of the work for which this permit is OWNER OR
OWNERS AGE
Issued (Sec. 3097, Civ. C.). �11&Willow
ADDRESS w
Lender's Name (X1W-0W1 2/ 7/91
Lender's Address .5526 1 AM 90-111
1 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 o