HomeMy Public PortalAbout10146 LYNROSE ST_Sewer__ WORKERS'COMPENSATION DECLARATION D
CE 808 (2-80) I�A I�P L I C AT I®N FOR PERMIT
CE 808 p
I hereby affirm that I have a certificate of consent to self SEWER—SEWAGE DISPOSAL
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800, Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN CONNECTION DATA
BUILDING /iy �J; STATION, DEPTH
F] Certified copy is filed with the county building inspection ADDRESS / V� y A/ v UPPER
'department' LOCALITY'iEMFL6 C f� MANHOLE Fi'E FE RENCE
LOWER
Date Applicant NEAREST C ✓l LlG/YdM f�N TYPE OF CONNECTION LENGTH FROM
CERTIFICATE OF EXEMPTION FROM WORKERS' cRoss ST.�YN Y, CURB P.L. M.L. TO P,L.
'sy` /� yI /J !� /' P.C. NO.
COMPENSATION INSURANCE OWNER \0�r� a "'`�� ��/W_M`�Du CO. IMP. NO. X06 NO.
(This section need not be completed if the work involved MAILADDRESS IIC1 .OS S TRUNK PERMIT NO. ROAD PERMIT NO. a
by the.permit is for one hundred dollars ($100) or less.) )' nn O
TiE/W AL+� �I Y TEL. NO. `�"(— gS V� AFFIDAVIT WAIVER EASEMENT RECORD. INSTR.NO. DATE
CITY (�
I certify that in the performance of the work for which this LEGAL
permit is issued, I shall not employ any person in any manner DESCRIPTION LOT NO. _3 HWY. OR ST. WIDENING
so as to become subject to the Workers' Compensation Laws. 0
/ �t O BLOCK TRACT STATE ENCROACHMENT U
Date t 1/� 4a_ PERMIT NO.
r Applicant NO. OF BLDGS, W
NOTICE O ALICANT: If, after aking this Certificate of slzE of LOT Now ON LOT U)
PP
Exemption, USE OF
p you should become subject to the Workers' CHARGES Z_
Compensation provisions of the Labor Code, you must forth-
BUILDINGS
with comply with such provisions or this permit shall beCONTRACTOR CONNECTION CHARGE FEE
deemed revoked.
' REIMBURSEMENT FEE ,
LICENSED CONTRACTORS DECLARATION ADDRESS
I hereby affirm that I am licensed under provisions of Chapter DISTRICT No. GROUP SK MAP PG PROC sseD BY
9 (commencing with Section 7000) of Division 3 of the Busi- CITY TEL. No.
ness and Professions Code, and my license is in full force and STATE CLASS Q� 3
LICENSE NO. CLASS
effect. NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO FINAL VALIDATION
License Number Lie.Class PUBLIC SEWER DATE
SEPTIC TANKSEEPAGE PIT OR
, ,
Contractor Date PITS AND/OR DRAINFIELD r _�^
FINAL
HOUSE SEWER CONNECTING To BY C
Q PRIVATE DISPOSAL SYSTEM ,.
I am exempt from the licensing requirements as I am a
CONNECT ADDITIONAL BLDG.OR
licensed architect or a registered professional engineer WORK TO HOUSE SEWER
acting In my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT,DRAINFIELD
iness and Professions Code). EXTN.,CESSPOOL,DRYWELL,MANHOLE
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
Lie.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's OWNERS Permit 8
License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE 1 LLZ2
ness and Professions Code):
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
aTRACTOR TOCONNECT THE ABOVE DESCRIBED EXISTING DWELLING
I, as owner of the property, will do the work and the TO THE PUBLIC SEWER.
structure is not intended or offered for sale (Section SIGNED THIS DAY OF t9_
7044, Business and Professions Code). owNER oR 1 7 0 2 A
OWNERS AGENT
CONSTRUCTION LENDING AGENCY ADDRESS # 0'0 0 0 1, 0
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is 2 0 0 1 ( O
issued(Sec. 3097,Civ.C.).
Lender's Name
' 000I4;000
Lender's Address
x,27 -81
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.
SEE REVERSE FOR EXPLANATORY LANGUAGE
AY���
f Signatur Permittee Date