HomeMy Public PortalAbout9931 LOWER AZUSA RD_Sewer__ WORKERS'COMPENSATION DECLARATION
r heFd'by tiff irm that I have a certificate of consent to self
Insure,or a certificate of Workers'Compensation Insurance,or M"2D
a certified cop ,Thereof(Sec 3Boo, Lab c I*-O002DPW 6/88 APPLICATION FOR PERMIT
Policy No�tampony �u AD N SEWER - SEWAGE DISPOSAL
Certiff copy is hereby furnish
❑ 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 EXEMPAON FROM WORKERS' BUILDINGo b ri
COMPENSATION INSURANCE ADDRESS - STATION DEPTH
(This section need not be completed if the work involved by the LOCAL �If' MANHOLE REFERENCE PPER
permit is for one hundred dollars(:100)or less) /� TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS STNEAREST F+V • Y CURB P t ML TOPI.
permit is issued, I shall not employ any person in any mannerP c NO
so as to become subject to the Workers'Compensation laws OWNER µ� ♦ • CO MAP NO JOB NO
Date Applicant =M404-0. LAS =04y
ft TRUNK PERANT NO ROAD PERMIT NO
-
NOTICE TO APPLICANT If, after making this Certificate of Cm • 4AV AFFIDAVIT I WAIVER EASEMENT RECORD INSTR NO DATE
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code,you must forthwith DESCRIPr1ON IOTNO HWY ORST WIDENING
comply with such provisions or this permit shall be deemed
revoked BLOCK TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO of �� PERMIT
I hereby offirm that I am licensed under provisions of Chapter st- BUIIZE OF LOT 2. �j•.s�NOOF
ON LOT or
9 (commencing with Section 7000) of Division 3 of the BusLDINGS t '{AL_ CHARGES
nese and Professions Code, and my license is in full force and ( C01 t1 ' CONNECTION CHARGE F
ff
eect I , ootarRAcrOR N7{.1si/�.r
License Num Lic Class ADDRESS
Contractor a Date
2.1 •9i DISTRICT NO GROUP MAP PROCESSED 8Y
P
STA
� LIC � sty v� BK PG
❑ I am exempt under Sec of the L A Co v' J • 3
Plumbing Code and/or Sec of the NO DESCRIPTION OF WORK FEE FINAL 4 �4
WR CONNECTING TO / DATE / „ ai /f VALIDATION Z
B 8 P Code for the following reason PUBLIC ZR ,6
K TANK SEWAGE PIT OR FINAL `
Dote PITS AND/Oft DRAINJ7ELD BY
HOUSE SEWER CONNIECTWG TO
PRIVATE V+LdI✓ CONNECT ADDITIONAL BLDG OR
tSPDW SYSTEM
Signature ,
WNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT —_ NFIELD
I hereby affirm that I am exempt from the Contractor's License EXM CESSPOOL ��MANHOUE
Low for the following reason(Secton 7031 5, Buisness and Pro- �sewEk RE ADIRIOR�ABANDON HOUSE SYSTEM iQ
fessions Code) i
❑ 1,as owner of the property,or my employees with wages as ACCT•T,
their sole compensation,will do the work and the structure s3D7 34.50
is not intended or offered for sale (Section 7044, Business
and Professions Code) OWNER'S Permit $ / 1 ITEM
El 1,as owner of the property,am exclusively contracting with AUTHORIZATION I TOTAL FEE '
licensed contractors to construct the project(Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HER NAMED OorRACTOR TO TOTAL 34.50
Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER
CONSTRUCTION LENDING AGENCYOEC► 34.5(
1 hereby affirm that there is a construction lending agency SIGt�ffDTH15 D JAW19� CHANE 10
for the performance of the work for which this permit Is OWNERS AGENT
Issued (Sec 3097,Civ C) ADDRESS f=14r+
Lender's Name ?-Ml 2/ 7/91
Lender's Address 55283 1 AM 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 lows regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upon the above-Mentioned property fox inspection purposes
Signature of Permittee Date BEE REVERSE FOR EXPLANATORY LANGUAGE