HomeMy Public PortalAbout4904 MCCLINTOCK AVE_Sewer__ WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent io self 92-0002 DPW 3/87 {1
insure, or a ceitificate of Workers'Compensation Insurance, or 76A642D 11�I
a certified copy thereof(Sec. 3800, Lab C.) `E BOB APPLICATION FOR PERMIT
Policy No._ Company
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
❑ Certified copy is filed with the county building inspectidr+ COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ADDREss STATION DEPTH
a�C
(This section need not be completed if the work involved by th¢ LOCALITY `� [ MANHOLE REFERENCE UPPER
OWER
permit is for one hundred dollars ($100)or less.)
NEAREST r^+ TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. V Y. CURB P,L. M.L TOP L.
permit is issued, I shall not employ any person in any manner P C.NO.
so as to become subject to he Workers''ompensgqa(((,��L'''i o ws. OWNER I�CI <� �y� CO.IMP.NO. JOB NO.
Date f ` Applicant t 7MAIL�� ADDRESS L J1,I, C'�1t96� UtS�zt TRUNK PERMIT NO. ROAD PERMIT NO.
NOTICE TO APPLICANT: If, a ter makin this Cer ficate 01' _�{j AFFIDAVIT WAIVER EASEME.PvT RECORD INSTR NO DATE
g CITY TEL.NO.
Exemption, you should become subject to th Workers' LEGAL
Compensation provisions of the Labor code, you m t forthwith DESCRIPTION LOT NO, HWY,OR ST WIDENING
comply with such provisions or this permit shall be deemed
revoked.
revoked. BLOCK TRACT STATE ENCROACHMENT - -'
LICENSED CONTRACTORS DECLARATION NO.of PERMIT No.
LOT
SIZE OF LOT NOW ON LOT '
I hereby affirm that I am licensed under provisions of Chapterr
9 (commencing with Section 7000 of Division 3 of the Busi- USE of
( g ) BUILDINGS CHARGES
ness and Professions Code, and my license is in full force and
effect. CONTRACTOR 1, 11tv CONNECTION CHARGE FEE
License Number Lic.Class ADDRESS REIMBURSEMENT FEE ✓�
r
DISTRICT NO. GROUP MAPPROCESSED BY
Contractor -Date �. CITY TEL NO. �"' � �'�' � ,7 PG
STATE LIC. >`
❑ 1 am exempt under Sec. of the L.A.Co. LICENSE NO. CLASS n i
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL g
HOUSE SEWER CONNECTINGTQ f DATE ,� VALIDATI01t�1,.
B. & P. Code for the following reason
PUBLIC SEWER
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD FI T ' m ® I C
Date -- HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM,
Signature .. CONNECT ADDITIONAL BLDG.OR �' '� -2 !,J C
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
I hereby affirm that I am exempt from The Contractor OVERFLOW SEEPAGE PIT,DRAINFIELD s License EXTN.,CESSPOOL,DRYWELL,MANHOLE
Law for the following reason (Secton 7031.5, Buisness and Pro ALTER,REPAIR OR ABANDON HOUSE '
fesslons Code): SEWER OR DISPOSAL SYSTEM pp
❑ 1, as owner of the property,or my employees with wages as r
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business r,
and Professions Code). OWNER'S Permit $
❑ 1, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE
licensed contractors to construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
Business and Professions Code). CONIVFCT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER,
CONSTRUCTION LENDING AGENCY ,
I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19�
for the performance of the work for which this permit is OWNER OR
issued (Sec. 3097, Civ. C.). OWNERS AGENT _
ADDRESS
Lender's Name
Lender's Address
I certify that I hove read this application and state that t
above information is correct. I agree to comply with all Cou. �
ordinances and State laws regulating Plumbing and Sewe t
and hereby authorize representatives of this County to ent>tir µ-
upon the ctbove•mentioned property for inspection purposes.GG a
ignature of Permittee D e SEE REVERSE FOR EXPLANATORY LANGUAGE .,