HomeMy Public PortalAbout5632 1/2 MCCULLOCH AVE_Sewer__ WORKERS'COMPENSATION DECLARATION 4n
1 hereby affirm that I have a certificate of consent to self Ilii
insure, or a certificate of Workers' Co ensgti Ins cynce, or 76Ae42D
P rt It Cal APPLICATION
ab C. ,� CE 808(REV.B,B,> APPLICATION FOR PERMIT
❑ Certified copy 's hereby furnished. SEWER - SEWAGE DISPOSAL
Certifi co is filed with th county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
t
Date Applicant �--��"---,�__ FADDRESS
FOR APPLI T TO FILL 1 CONNECTION DATA
TIFI ATE OF EXEMPT ON FROM WORKERS'
COMPENSATION INSURANCE STATIO j DEPTH
(This section need not be completed if the work involved by the C MANHOLE REFERENCE UPPE
permit is for one hundred dollars ($100)or less.) LOW R
- TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this Y CURB P.L, M.L.TO P.L.
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws. L P,B NO. ,
OWNER CO.IMP,NO. JOB NO. �.
MAIL "'�`
Date Applicant ADDRESS TRUNK PERMIT NO ROAD PERMIT NO.
NOTICE TO APPLICANT: If, after makingthis Certificate of j/ �"7 AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO DATE
CITY 6 i_`4/ TEL.NO. ^�"'��
Exemption, you should become subject to the Workers' LEGAL �+�
Compensation provisions of the Labor code, you must forthwith DESCRIPTION HWY.OR ST.WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT STATE ENCROACHMENT,
LICENSED CONTRACTORS DECLARATION No.OF BLDGS. PERMIT No.
SIZE OF LOT NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter USE OF �r
9 (commencing with Section 7000) of Division 3 of the BUST- BUILDINGS CHARGE
ness and Professions Code, and my license is in full force and d
effect. �. CONTRACTOR ( J T� YJ�/L ' CONNECTION CHARGE FEE s�
8.
License Numb Lic.Class ADDRESS REIMBURSEMENT FEE
Contractor L� '�-- Date J" DISTRICT No. GROUP MAP PROCESSED BY u
CITY TEL,NO. BK PG Z
STATE LIC.
❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. Class P 3 F
NO. DESCRIP ION OF WORK FEE L)
Plumbing Code and/or Sec. of the FINAL VALIDATION a
HOUSE SEWER CONNECTING T9 DATE
B. & P. Code for the following reason Puauc SEWER y 1 H
SEPTIC TANK,SEEPAGE PIT OR Z
PITS AND/OR DRAINFIELD FINAL
Date HOUSE SEWER CONNECTING TO BY h
PRIVATE DISPOSAL SYSTEM UA
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 _ 1
Law for the following reason (Secton 7031.5, BUisness and Pro- ALTER,REPAIR OR ABANDON HOUSE 1 ®'• ® • ll
fessions Code): SEWER OR DISPOSAL SYSTEM J t❑ t ry, 5 p V,• • '2 I,as owner of the property,or my employees with wages as
their sole compensation, will do the work and the structure • ® n
is not intended or offered for sale (Section 7044, Business
'I,:5 C5
and Professions Code). OWNER'S Permit g UU e 7
❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE
licensed Contractors to construct the project (Section 7044, 1 HAVE AT 'MIS 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 permitis OWNER OR
issued (Sec. 3097,.Civ. C.). OWNERS AGENT
ADDRESS
Lender's Name
Lender's Address
I certify that I have read this application and state that the
abytho
on is rect. I agree to comply with all County
orto aws regulating Plumbing and Sewers,
anoriz representatives of this County to enter
upme do d property for inspection purposes.
S6 nature o rmii Dae Ir SEE REVERSE FOR EXPLANATORY LANGUAGE