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HomeMy Public PortalAbout5313 MCCULLOCH AVE_Sewer__ WORKERS' COMPENSATION DECLARATION 4 hereby-affirm that I have a certificate of consent to self 920002 DPW 3/87 insure, or o certificate of Workers'Compensation Insurance, or CE 64 a certified copy thereof (Sec. 3800, Lab C.)_ , ; APPLICATION FOR PERMIT Policy No.____T__,Company {,; ©s Cf� Certified copy Is hereby furnished. SEWER - SEWAGE DISPOSAL Q Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. „ Date %_Applicant _ 'I _ FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDwG " COMPENSATION INSURANCE ADDRESS y _' STATION DEPTH (This section need not be completed if the work involved by theMANHOLE REFERENCE UPPER LOCALIT permit is for one hundred dollars ($100)or less.) NEARESv — — -- _ — LOWER I certify that In the performance of the work for which this CROSSST, TYPE OF CONNECTION LENGTH FROM __ Y. CURB R.L. M,I.TO P,I. permit is issued, I shall not employ any person in any manner ----- - so as to become subject to the Workers Compensation Laws. _ P.c. No I ens p OWNER I- CO.IMP,NO. JOB NO. MAIL i s TRUNK PERMIT NO, ROAD PERMIT NO. Date Applicant ADDRESS NOTICE TO APPLICANT: If, after makingthis Certificate of f AFFIDAVIT WAIVER EASEMENT RECORD.INSTR,NO DATE CITY r rEL No. Exemption, you should become subject to the Workers' LEGAL i 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 ) c, revoked. BLOCK TRACT .,:; �' I STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO.of LOT "n PERMIT No. LOT SIZE OF LOT NOW ON ' I hereby affirm that I am licensed under provisions of Chapter USE 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. CONTRACTOR (- CONNECTION CHARGE FEE License Number ___Lic.Class__, ADDRESS '; .rc REIMBURSEMENT FEE . r ,... ' f DISTRICT NO. GROUP MAP PROCESSED BY Contractor Date CITY TEL NO ❑ SK PIG TATE LIC. I am exempt under Sec. of the L.A.Co. LICENSE No. CLASS J'L Plumbing Code and/or Sec. of the NO. DESCRIPTION 00 WORK FEE FINAL `•. HOUSE SEWER CONNECTING TO PUBLIC SEWERDATE VALIDATION f B. 8 P. Code for the following reason Wi SEPTIC YANK,SEEPAGE PIT OR FINAL ` ,�% Wi PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR , OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Secton 7031.5, Buisness 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 I Permit g /-6 `'r �r I I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE licensed contractors to construct the project Section 7044, .... p I ( I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY ► r 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 P p OWNERS AGENT issued (Sec. 3097,,Civ. C.), ADDRESS Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all County ordinance$:;and State laws regulating Plumbing and Sewers, and here authorize representatives of this County to enter upon the ove-mentioned property for inspection purposes. Signotu of Petfnittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE