HomeMy Public PortalAbout5634 1/2 MCCULLOCH AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
1 hereby affirm that I, have a certificate of consent to self
insure, or a certificate of Workers'Compensot' n insurance, or 76A642D
tif; re eoSmpany CUs
ssoo/Lab�., CE 8G8(REV.8i81j APPLICATION FOR PERMIT
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❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
ertifie cpy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
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Date pplicant FOR AP 1CANT TO FI IN CONNECTION DATA
CEATE OF EXEMPTION FROM WURKERS' FNEAREST
STATION �' DEPTH n
COMPENSATION INSURANCE
This section need not be completed if the work involved b theC4 1�1 UPPER
( p y MANHOLE REFERENCE VER
permit is for one hundred dollars ($100)or less.)
I certify that in the performance of the work for which this .3' .�_ TYPE OF CONNECTION LENGTH FROM
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permit is issued, I shall not employ any person in any manner CURB P.L. M.LTO P.L,
NO-
so as to become subject to the Workers' Compensation Laws. pW'NER -"� CO.IMP.NO. JOB NO,
MAILT."! , �i TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS INSTR Nq DATE
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NOTICE TO APPLICANT: If, after making this Certificate of CITY q,r 3�t TEL.Nq AFFIDAVIT WAIVER EASEMENT RECORD.
Exemption, you should become subject to the Workers' LEGAL ifvfj"
Compensation provisions of the Labor code, you must forthwith DESCRIPTION 11T NO HWY.OR ST.WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT STATE ENCROACHMENT x /
LICENSED CONTRACTORS DECLARATION NO OF BLDGS PERMIT No.
SIZE OF LOT NOW ON LOT 1, +
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 LARGES
ness and Professions Code, and my license is in full force and
effect. �" .. CONTRACT /�s�.Q,-� o CONNECTION CHARGE FEE L�
ADDRESS >_
License Numb 4 J LiC.Class- /.�--�---_., REIMBURSEMENT FEE
.�
Contract Date "� - DISTRICT NO. GROUP MAP PROCESSED BY
CITY TEL,NO. BK PG Z
STATELIC. O
❑ I amexempt under Sec. of the L.A.Co. LICENSE NO. CLASS ,C'J
NO. DSC Y0 ,1'WORK FEEPlumbing Code and/or Sec. of theFINAL \ J VALIDATION
HOUSE SEWER CONNECTING TO �""" DATE 1 +,��
B. & P. Code for the following reason PUBLIC SEWER 4A
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD FINAL 1 (`!
t
Date
"-- HOUSE SEWER CONNECTING TO BY P =<.= �� 9PRIVATE DISPOSAL SYSTEM �t
Signature CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER , V
OVERFLOW SEEPAGE PIT.DRAINFIELD
hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE p i
7,
Law for the following reason (Becton 7031.5, Buisness and Pro- ALTER.REPAIR OR ABANDON HOUSE is
fessions Code): SEWER OR DISPOSAL SYSTEM ..1
❑ 1, as owner of the property,or my employees with wages as
their sole compensation, will do the work and the structure 1t ' ,-- ; 7
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permit I❑ I,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 NAM
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE CONSTRUCTION LENDING AGENCY ,I hereby affirm that there is a construction lending agency SIGNED THISDAY OF
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 at I have d this application and state that the
above i f rmatia s C rect. I agree to comply with all Cou ty
ordina c and tate ws regulating Plumbing and Sew rs,
and h re y au horize repre entatives of this Cou y to nter
upon t abov -menti ned roperty for inspection urpo e/
Si ature of Per It ee Date SEE REVERSE FOR EXPLANATORY LANGUAGE