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WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensa . }nsur ce�4r 76A642D
a erI fled/ p� therrof (Sec. 3800 orb C ) / _ E808(REV,a 811 APPLICATION FOR PERMIT
' �.t S Compan ^�, <"�< ✓✓ �,, ins
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
t'd
Ced with the cpunty building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
e r e i. sY��"�e Applicant 6 FOR APPLICANT TO F L INCONNECTION DATA
E IFICATE OF EXEMPTION FROM WORKERS' BUILDING
COMPENSATION INSURANCE A.DDREss STATION DEPTH
(This section need not be completed if the work involved by the LOCALITY MANHOLE REFERENCE LOW R
permit is for one hundred dollars ($100)or less.)
I certifythan the performance of the work for which this NEAREST > / h TYPE OF CONNEC ION LENGTH FROM
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P CROSS 5T. L./I/ Y, CURB P.L. MA.TO P.L.
permit is issued, I shall not employ any person in any manner � q P.C.No.
so as to become subject to the Workers'Compensation Laws. OWNER '/v CO.IMP.NO. JOB NO.
MAIL TRUNK PERMIT NO. ROAD PERMiT NO.
Date Applicant ADDRESS
AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL NO.
Exemption, you should become subject to the Workers' LEGAL t +t
Compensation provisions of the Labor code, you must forthwith DESCRIPTION teF NO. HWY.OR ST,WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT STATE ENCROACHMENT /T
NO.OF BLDGS. PERMIT NO. , L L-
LICENSED CONTRACTORS DECLARATION 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- BUILDINGS CHARGES
ness and Professions Code, and my license is in full force and
effect. O,'�J�.'(Jj' CONTRACTOR -. "� CONNECTION CHARGE FEE t(� 57 CL
License Numb@�'—^'___LIC.Class— r ADDRESS REIMBURSEMENT FEE O
Contractor/T"�iw�"�"` Date (74 � DISTRICT NO. GROUP MAP PROCESSED BY V
CITY TEL NO. BK PG Z
�"` C.
❑ 1 am exempt under Sec. Of the L.A,CO. STATE LIQ
LICENSE NO. CLASS
V.
Plumbing Code and/or Sec. ofthe NO. .DFS_RIP ION OFORK FEE FINAL - l VALID 4'TIO[�; A a
HOUSE SEWER CONNECTING TO .�—� DATE
ZB. & P. Code for the following reason PUBLIC SEWER SEPTIC TANK,SEEPAGE PIT OR FINAL . y a
PITS AND,'OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO BY f
PRIVATE DISPOSAL SYSTEM "T 01(T
SignatureCONNECT ADDITIONAL BLDG.OR 6 I
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD , g. � g ��'7
I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWEU,MANHOLE
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM 09,06-8 7
❑ I, as owner of the property,or my employees with wages as
their sale compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNERS Permit 5 (j
❑ 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 (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
above in tion is ect. I agree to comply with all County
ordinanc nd e ws regulating Plumbing and Sewers,
and her a oriz rep esentatives of this County to ent
upol 1 bo @-me tion property for inspection rposes
gnatureof ermittee �� Date SEE REVERSE FOR EXPLANATORY LANGUAGE