HomeMy Public PortalAbout9933 LOWER AZUSA RD_Sewer__ WORKERS'COMPENSATION DECLARATION
r h6reby wffirm that 1 have a certificate of consent to self
ensure,or a certificate of Workers'Compensation Insurance, or 7GA642D
a cerhfWd c sgere f(Sec 3800 tab C) M 02-OM"°/88 APPLICATION FOR PERMIT
POIiq No talnpany tj"f�e� A O SEWER - SEWAGE DISPOSAL
CertefebcTcpyoes hereby fumhh
❑ Certified copy is filed with the court'building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
deportment
Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EX ON FROM WORKERS'
STATIONDEPTHCOMPENSATION INSURANCE AuoRN � � w�.• Y
(This section need not be completed of the work involved by the pt..' OtT4 MANHOLE REFERENCE UPPER
permit is for one hundred dollars(=100)or less) LOCALITY
I certify that in the performance of the work for which this CR t.� W 94 AVCS • TYPE OFOONURB LENGTH P I.
permit is issued, 1 shall not employ any person in any manner Y CURB P O TOP L
so as to become subject to the Workers'Compensation Laws OWNER t1J • PAQeo •G Pc NO
� //��..�� ao IMP No roe No
MAIL
Date Applicant ADDRESS r. f�-WLJ�a #2 TRLMIX PERMIT NO ROAD PERMIT NO
NOTICE TO APPLICANT If, after making this Certificate of CITYZ6114 "811JO(+TEL NO 1b(g . eA-" 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 2• HWY OR ST WIDENING
comply with such provisions or this permit shall be deemed
revoked BLM TRACT Q STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION No oP BtoGs � n! PERMIT"°
1 hereby affirm that I am licensed under provisions of Chapter USE
OF LOT Q D�O SP.NovW oN LOT
usE oP
9 (commencing with Section 7000) of Division 3 of the Buse- BUILMNGs 9051 1>0&YM I. CHARGES
nese and Professions Code, and my license is in full force and j
effect 1 ' CONTRACTOR S/ �a IQ�• CONNECTION CHARGE I$
License Num�bjer ipw Lic Class q ADDRESS . (ASTAW PEE
Contractor Date • 1 I a •14*0 DISTRICT NO GROUP MAP PROCESSED BY Z
CITY PG C3 STATE
LK
I am exempt under Sec of the L A Co UCMSE NO
D afvnoN OF WOR � VALIDATION N
Plumbing Code and/or Sec of the FlNAL d.
B &P Code for the following reason �,qqNWIE(,SEEPAGE HOUSE SEWER OR � ��TO DATE —�� Z
PITS ANO OR DRAAWIEID
Date MOUSE SEWER CONNECTING TO BYIVATE DISPOSAL SYSTEM_
Signature VM CONNECT ADDITIONAL BIDE OR ,
O NER-BUILDER DECLARATION WORIi To HOUSE SEWER
I hereby affirm that I am exempt from the Contractor's License OVERFLOW
EXTN
Law for the following reason(Secton 7031 5, Buisness and Pro- ALTER REPAIR OR ABANDON HOUSE
fesseons Code) sEwEd OR DISPOSAL SYSTEM
❑ 1,as owner of the property,or my employees with wages as Ac4T.r
their sole compensation,well do the work and the structure DC7 X
is not Intended or offered for sale (Section 7044, Business
and Professions Code) OWNER'S I Permit t I jTM
❑ 1,as owner of the property,am exclusively contracting with AUTHORIZATION1 TOTAL FEE TOTAL 34 cO
licensed contractors to construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAME CONTRACTOR To
Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELMIG TO THE PUBLIC SEWER _
CONSTRUCTION LENDING AGENCY wmpgQy� � ��
I hereby affirm that there is a construction lending agency SIGNED IS D OF � r 19M pop ,Gil
for the performance of the work for which this permit Is OWNER OWNERS AGENT
Issued(Sec 3097, Civ C)
Lender's Name ADDRESS 2/ Mi.
Lender's Address I AM 7:131
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