HomeMy Public PortalAbout9927 LOWER AZUSA RD_Sewer__ WORKERS'COMPENSATION DECLARATION
I"hereby 8ffirrrT that I have a certificate of consent to self
insure, or a certificate'of Workers'Compensation Insurance,or 76A642D
a certified cop thereof(Sec. 3800, Lab C.) 924002 DPW 6/418 APPLICATION FOR PERMIT
Policy Nag11DD •Company som`n u� SEWER - SEWAGE DISPOSAL
Certif; copy is hereby furnisFer�
❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
doa°rtment. •
Date Applicant ��' FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING 2 1 �,1�1111� •i.l
COMPENSATION INSURANCE ADDRESS �.VJJ^^���p W • STATION DEPTH
(This section need not be completed if the work involved by theMANHOLE REFERENCE UPPER
permit is for one hundred dollars(=100)or less.) LOCALITY
—rum ILENGTH FROM
I certify that in the performance of the work for which this CRROOSS STS. � Y. TYPE CURB P.L. M.L.TO P.L.
permit is issued, I shall not employ any person in any manner
!� 1 P.C.NO.
so as to become subject to the Workers'Compensation Laws. OWNER � • �O • �N CO:IMP,NO. JOB NO.
MAILl TRUNK PERMIT NO. 'ROAD PERMIT NO.
Date Applicant Amu • 1r
NOTICE. TO APPLICANT: If, after making this Certificate of CITY MW 10)SH• AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code,you must forthwith DESCRIPTION LOT NO. a/ra 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, '�� 5 • NOW ON LOT No• &h N
PERMIT
I hereby affirm that I am licensed under provisions of Chapter a OF
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS I l.- CHARGES
ness and Professions Code, and my license is in full force and J ,
effect. r ' CONTRACTOR M O t1JG• CONNECTION CHARGE FEE
License Number ,Vq—/ �7 Lic.Classn • L.L�i iu REIMBURSEMENT FEE y!
Contractor Of Dafe '`� •� I CITY 1AaA DISTRICT NO. GROUP MAP SSED BY g.
STATE UC. + • f/'rV p� BK PG V
❑ 1 am exempt under Sec. of the L.A.Co. LICENSE NO. 1 Cuss
Plumbing Code and/or Sec. of the NO. ' DESCRIPTION OF WORK FEE FINAL a
HOUSE SEWER CONNECTING TO DATE �f VALIDATION iA
!— 1
B. 8 P..COdPUBLIC SEWERe for the following reason SEPTIC TANK SEEPAGE PIT OR FINAL Z
.PITS AND/6k DRAINFIELD
Rafe SEWER CONNECTING TO 8Y
HOUSE
Signature ���'� PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG.OR
O ER-BUILDER DECLARATION WORK TO HOUSE SEWER Poo.
SEEPAGE PIT DRAINFIELD -
I hereby offirm that I am exempt from the Contractor's License EXTN. CESSPOOL DRY�L MANHOLE i�y
Low for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE 10
fessions Code): SEWER OR DISPOSAL SYSTEM AGCT■a .
❑ 1,as owner of the.property,or my employees with wages as
their sole compensation,will do the work and the structure 3307 34.511
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permit $ 1 ITEM
❑ 1,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE 4V TOTAL 34. 50
licensed contractors to construct the project-(Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON ACTOR TO
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CHECK
HE K 3
4 a 5101CONSTRUCTION LENDING AGENCY v"
DAY �
I hereby affirm that there is a construction lending agency SIGNED THIS F 19CHANGE ' X1'
for the performance of the work for which this permit is . . OWNER OR
issued (Sec. 3097, Civ. C.). OWNERS AGENT
Lender's Name - L ADDRESS 1 2/ 7/91
Lender's Address 5527 1 APS 9:01
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 Dote SEE REVERSE FOR EXPLANATORY LANGUAGE