HomeMy Public PortalAbout5821 MUSCATEL AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
!hereby affirm that 1 have a certificate of consent to self
insk�re, or a certificate of Workers'Compensation Insurance, or 78A842D
a c4irtifi 4d copy thereof (Sec. 3800, Lab C.) 92-0002 DPW6/68 APPLICATION FOR PERMIT
Policy No. Company + SEWER - E
❑ Certified copy is hereby furnished. - SEWAGE DISPOSAL
❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department. *
Date Applicant FOR APPLICANT TO FILL IN � r ;, CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING < STATION DEPTH
COMPENSATION INSURANCE ADDRESS
This section need not be completed if the work involved b the UPPER
( p Y LOCALITY MANHOLE REFERENCE '+,. i �f WER '
permit is for one hundred dollars(E100)or less.) P^ ! r.' ,r O
I certify that in the performance of the work.,for LENGTH FROM
NEAREST TYPE OF C
for which this ceoss ST. Y. Cog P.l. M.L ro P.L.
permit is issued, I shall not employ any person iii any manner P.C.No.
so as to become subject to the Workers' Compensation Laws. OWNER CO.IMP.NO. JOB NO.
MAIL
Date-11111 _Applicant 4fi,^ ADDRESS _ TRUNK PERMIT NO. ROAD PERMIT NO-
NOTICE TO APPLICANT: If, after making CITYTEL NO.
this Certificate Of AFFIDAVIT =MENT RECORD.INSTR,NO. DATE
.. �
Exemption, you should become subject to the Workers' LEGAL
DESCRIPTION-- --
Compensation provisions of the Labor code, you must forthwith LOT NO. 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.
I hereby affirm that 1 am licensed under provisions of Chapter SIZE OF LOT NOW ON LOTUSE 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 a d
effect. ` , CONNECTION CHARGE FEE
f �"r','7 f CONTRACTOR
CL
License Number Llc.Class
ADORES a REIMBURSEMENT FEE
f "'!`Date , y; DISTRICT NO. GROUP MAP PROCESSED BY Z
COntraCTat -c. ,- CITY TEL.NO. BK PG
❑ I am exempt under Sec. _of the L.A.Co. LICENSE NO. d CLnss'
Plumbing Code and/or Sec. of The NO. DESCRIPTION OF WORK FEE FINAL// 7 -
HOUSE SEWER CONNECTING TO j DATE VALIDATION
PUBLIC SEWER UI
�.f 4 "�
B- & P. Code for the following reason 2'
SEPTIC TANK,SEEPAGE PIT OR FINAL y A
PITS AND/OR DRAINf1ELD
Date HOUSE SEWER CONNECTING TO BY 1 -
PRIVATE DISPOSAL SYSTEM �F
Signature CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
I hereby affirm that I am exempt from the Contractor's License OVERFLOW SEEPAGE PIT,DRAiNFIELDEXTN.,CESSPOOL DRYWELL,MANHOLE
Law for the following reason (Sectors 7031.$, BulsnesS and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM
❑ I,as owner of the property,or my employees with wages as " p
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permit $
❑ 1,as owner of the property,am exclusively contracting with AUTHORIZATION I TOTAL FEE
licensed contractors to construct the project (Section 7044,
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONT~ TMJ
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUB--- - rk
CONSTRUCTION LENDING AGENCY , a
I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF t 19_ _
for the performance of the work for which this permit is OWNER OR
slued (Sec. 3097, Civ. C.)- OWNERS AGENTADDRESS
Lender's Name
Lender's Address I'd
I certify that I have read this application and state that the n
ar
above information is correct. I agree to comply with all County r s
ordinances and State laws regulating Plumbing and"Sewers,
and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes.
.c f
ignature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE