HomeMy Public PortalAbout5638 MCCULLOCH AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self 1
insure, or a certificate of Workers'Compensation Insurance, or 76Ae47D
acere,� t eG f abC.),� EBOBIREV.e,8>> APPLICATION FOR PERMIT
Policy No. ���Pa;�_ r s
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
ertifie co s filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
e art a t.
Date F Applicant ,+� �^--- FOR APPLICANT TO FILL I CONNECTION DATA
CE FICA7E OF EXEMPTION FROM WORKERS' FDRE
ING ?
COMPENSATION INSURANCE ESS ( STATIO DEPTH
(This section need not be completed if the work involved by the �* MANHOLE REFERENCE
permit is for one hundred dollars ($100)or less.) LITY c_C_ c owE
EST TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this S ST. t/ (� Y,1 cuRB P.L. MA 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. r---^ P.C.NO, d� r�
I P ER CO.IMP.NO. .LOB NO,
J C..
- TRUNK PERMIT NO, ROAD PERMIT NO.
Date Applicant ESS / �
NOTICE TO APPLICANT: If, after making this Certificate Of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
g - T TEL.NO, 3
Exemption, you should become subject to the Workers' GAL cCompensation provisions of the Labor code, y0U rT1u5t forthwith RIPTION ^t6T NO. H'JVY.OR ST.WIDENING
comply with such provisions or this permit shall be deemed
revoked. K s TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION �N OF BLDGSPERMIT No.F LOT NOW ON LOTklj
I hereby affirm that I am licensed under provisions of ChapterF9 (commencing with Section 7000) of Division 3 of the Busi- INGS CHARGES
ness and Professions Code, and my license is in full force and
effect. CONTRACTOR
1���--. CONNECTION CHARGE FEE , '� '"'� CL
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License Numb Lic.Class _ ADDRESS REIMBURSEMENT FEE 0
Contractor �'�'� Date ' ""iJ ; CITY TEL NO. DISTRICT NO. GROUP C. BK MAP P� PROCESSED BY Z
❑ I am exempt under Sec. of the L.A.Co. STATE
rl�NO. c Ss O
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NQ DESCRIPTION OF WORK FEE V
Plumbing Cade and/or Sec. of the r DATE I VALIDATION a
HOUSE SEWER CONNECTING TO r DATE
PUBLIC SEWER 'L�
B. $ P. Code for the following reason SEPTIC TANK SEEPAGE PIT OR J Z
PITS AND/OR DRAINFIELD FINAL
f
Date HOUSE SEWER CONNECTING TO BY ,
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER ►
I hereby affirm that I am exempt from the Contractor's license EEXTN.,CESSPOOL,DR IYY✓uAMANHOLE
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 u # Q
El
their sole compensation, will do the work and the structure r B 2,7,J 0
is not intended or offered for sale (Section 7044, Business - 7, A
-
and Professions Code). OWNERS Permit ' ;
❑ 1, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE `� t„ 0 U 7
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 pop.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 have read this application and state that the
abov/thov
tion ' rect. I agree to comply with all County
ordinnd ate ws regulating Plumbing and Sewers,
and ou oriz representatives of this County to enter
upon -me bone property for inspection purposes.
Y7
nature o rmittee _Date SEE REVERSE FOR EXPLANATORY LANGUAGE