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HomeMy Public PortalAbout5636 MCCULLOCH AVE_Sewer__ t WORKERS'COMPENSATION DECLARATION I hereby affirm that i have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance, or 76A642D a c tlfie "tZr (Sec. 3800, C.) CE 808(REV.8,'81) APPLICATION FOR PERMIT Poli o. Company _ ©s ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL Certified opy Is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY e t ent. Date Applicant FOR APPLICANT TO FILL 1 CONNECTION DATA C R IFICATE OF EXEMPTION FROM WORKERS' BUILDING COMPENSATION INSURANCE ADDRESS STATION l DEPTH (This section need not be completed if the work involved by the LOCA ✓ "� MANHOLE REFERENCE ' UPPE permit is for one hundred dollars ($100)or less.) NEAREST -.ER_ NEAREST J � ,r _ *y TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST. ( 41 r -7 / 4 Y CURB P.L. M.L,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. OWNER r CO.IMP_NO. J08 NO. MAIL i TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS _ °- -7Z-A4 NOTICE TO APPLICANT: If, after making this Certificate of CITY �Yu. � AFFIDAVIT WAIVER EASEMENT RECORD,INSTR.NO, DATE TEL NO !✓ Exemption, you should become subject to the Workers' LEGAL ( �J' Compensation provisions of the Labor code, you must forthwith DESCRIPTION ..�f No. HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed a revoked. BLOCK TRACT STATE ENCROACH: T + LICENSED CONTRACTORS DECLARATION NO.OF SLDGS. PERMIT NO.SIZE OF LOT Now oN LOT I hereby affirm that I am licensed under provisions of Chapter ".USE OF y.�.. 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.. T; CONNECTION CHARGE FEE ,J �t,y� License Numbed Class—e ^� ADDRESS REIMBURSEMENT FEE ` ' DISTRICT NO. 'GROUP MAP P3CESSED BY U Contractor i .f��'�""� Date CITY TE O. BK PG '• ❑ I am exempt under Sec, of the L.A.Co. uceNSE No. anss 0 NO. DESCRIPTION '4WR FEEPlumbing Code and/or Sec. of theFINAL VALIDATION a HOUSE SEWER CONNECTING TO . DATE B. 8 P. Code for the following reason PUBLIC SEWER ✓ y� SEPTIC TANK,SEEPAGE PIT OR FINAL z 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,DRAINFIELDAINfOR I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLEl Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER REPAIR OR ABANDON HOUSE fessions Code)' SEWER OR DISPOSAL SYSTEM ❑ 1,as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure w.,,r p is not intended Or offered for sale (Section 7044, Business and Professions Code), OWNER'S Permit ® ® ® � 9 0 ❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE licensed contractors to construct the project Section 7044, ® g 7'"J P I ( 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREI Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING T '7 !GCONSTRUCTIONLENDING AGENCYSIGNED THIS DAY OF [' �1 67 I hereby affirm that there is a construction lending agency , 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 1 certify tho have read this application and state that the abofthb tion ' rrect. I agree to comply with all County ordtate laws regulating Plumbing and Sewers, andthori re sentatives of this County to enter upoe-m tion property for inspection purposes. —} Silignature Permittee Date s c SEE REVERSE FOR EXPLANATORY LANGUAGE