HomeMy Public PortalAbout5308 MCCLINTOCK AVE_Sewer__ • WORKERS'COMPENSATION DECLARATION ;
� 1 hereby affirm that I have a certificate of consent to self 92-0002 DPW 3/87 I
insure, or a certificate of Workers'Compensation Insurance, or 76A642D
a certified copy thereof (Sec. 3800, Lab C.) CE 808 APPLICATION FOR PERMIT
Polic No.l f 1 Com an i _ �_ CP - v
y p y� SEWER - SEWAGE DISPOSAL
El Certified copy is hereby furnished.
Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Date j Applicant !' =' r FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDINGSTATION DEPTH
�-
COMPENSATION INSURANCE ADDRESS ! (
This section need not be completed if the work involved b UPPER
( p y the LOCALITY MANHOLE REFERENCE LOWER
permit is for one hundred dollars ($100)or less.) - — -
certifythat in the performance of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROM
e P CROSS 5T. Y. CURS P.L. M I.TO P.L.
permit is issued, I shall not employ any person in any manner -- —
so as to become subject to the Workers Compensation CO.IMP
Com ensatiLP. B NO.
p OWNER .NO. JOB NO,
MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRFts --`-- - -- -- — —
NOTICE TO APPLICANT: If, after makingthis Certificate Of AFFIDAVIT WAIVER EASEMENT RECORD,INSTR,NO. DATE
cn'Y _ r_el do
Exemption, you should become subject to the Workers' LEGAL _
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO, HWY.OR ST.WIDENING
comply with such provisions or this permit shall be deemed — -- ---
revoked. BLOCK TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO OF Biocs PERMIT No.
I hereby affirm that I am licensed under provisions of Chapter SIZE OF LOT NOW ON LOTUSE OF
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES
ness and Professions Code, and my license is in full force and -- -- —'
effect. OONTRACTOR = l \/' CONNECTION CHARGE FEE
License Number Lic.ClasI; ADDRESS REIMBURSEMENT FEE O
i Contractot�` DateCITY 'L. .JG. DISTRICT NO. GROUP MAP PROCESSED BY L)
{ , .
STATE --- --- LIC. --- BK PG Z
❑ I am exempt under Sec. of the L.A.Co. LICENSE NO a` crass f r �� ~
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEEL
FINAL W
HOUSE SEWER CONNECTING TO DATE VALIDATION
B. & P. Code for the following reason Pueuc seweR e / - ,- �
SEPTIC TANK,SEEPAGE PIT OR FINAL Z
PITS AND/OR DRAINFlELD
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR Poo.DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFlELD
I hereby affirm that I am exempt from The Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE
Law for the following reason (Secton 7031.5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL.SYSTEM
❑ I,as owner of the property,or my employees with wages as
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permit $ e-c"
❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE , � s
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO "
Business and Professions Cade). CONNECT 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
).�,.-Z- ,! ADDRESS
Lender's Name �, _`
Lender's Address J " ?' '
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 th'e bbove-mentioned property for inspection purposes.
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE