HomeMy Public PortalAbout5632 MCCULLOCH AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' mpensat n Insu rote, or 16A642D
a c E d t ereof Sec. 3B , ab C. CE eoa{REV.8/81)
Pam Company ` r � «$ APPLICATION FOR PERMIT
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
`ertified o s filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
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Date Applicant i FOR APPLICT T ,(SILL IN CONNECTION DATA
E IF ATE OF EXEMPTION FROM WORKERS' BUILDING � �n, Lz
STATION DEPTH
COMPENSATION INSURANCE ADDRESS ids-.
(This section need not be completed if the work involved by The LOCALITY �'� MANHOLE REFERENCE UPPE
LOWE
permit is for one hundred dollars ($100)or less.)
NEAREST ; -
I certify that in the performance of the work for which this CRoss ST. TYPE OF CONNECTION LENGTH FROM
CURB P.L. M L TO P,I,
permit is issued, I shall not employ any person in any manner y
so as to become subject to the Workers'Compensation Laws. OWNER ' ✓'� CO IMP.NO. 44 JOB NO. 7—
MAIL
K /ter. TRUNK PERMIT NO. ROAD PERMIT NO,
Data Applicant ADDRESS l
NOTICE TO APPLICANT: If, after making this Certificate of CITY d> AFFIDAVIT WAIVER EASEMENT RECORD,INSTR.NO DATE
),j'L�Y TEL.NO. �
Exemption, you should become subject to the Workers' LEGAL
3-4/1
Compensation provisions of the Labor code, you must forthwith DESCRIPTION rewr�. � _ HWY.OR ST.WIDENING
comply with such provisions or this permit shall be deemed
revoked, BLOCK TRACT STATE ENCVOACIAMENT
:
LICENSED CONTRACTORS DECLARATION NO.fffF BLDG& PERMIT NZ y
SIZE OF LOT NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter USE OF
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGSHARGES
ness and Professions Code, and my license is in full force and `, -
effect. CONTRACTOR - CONNECTION CHARGE FEE l� }'::i)C.�;:: t
License NVm C.Class_ ADDRESS REIMBURSEMENT FEE
r ; DISTRICT NO. I GROUP MAP PROCESSED BY V
Contractor � � Date s CITY TEL - -, ,- `� BK PG i� '� ,r, z
r STATELIC, y 9 .�
❑ I am exempt under Sec. of the L.A.Co_ ucENSENo: ASS O
NO. D,SC TI N OF ORK FEE
H
Plumbing Code and/or Sec. of the FINAL VALIDATIONLU
HOUSE SEWER CONNECTING TO .,o' DATE , �. y; 0.
B. PUBLIC SEWER P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR a Z
PITS AND/OR DRAINFIELD FINAL
Date HOUSE SEWER CONNECTING TO BY t
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 ► ra i 8 S 6 A.
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM ( .a0 i , 'L
❑ I, as owner of the Property,or My employees with wages(is ( 0
z.. 7, �:�0
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business 2 7, `1 0 Y
and Professions Code). OWNERS Permit s 0
❑ 1,as owner of the property; am exclusively contracting with AUTHORIZATION TOTAL FEE '?
licensed contractors to construct the project (section 7044, 1 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
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 (Sac. 3097, Civ. C.). OWNERS AGENT
ADDRESS
Lender's Name
Lender's Ad ss_ _
I certify t t i hpav6 rea this application and state that the
above in r on is car ct. I agree to comply with all County
ordnan e nd State Ws regulating Plumbing and Sewers,
and h r outhoriz re PeSentafives of this County to enter
upo a ve-m do d property for inspection purpos
s
Signature ermittee ate -- - SEE REVERSE FOR EXPLANATORY LANGUAGE
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