HomeMy Public PortalAbout6133 MUSCATEL AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
Iffirm that I have a certificate of consent to self
certificate of Workers'Compensation Insurance, or 76A642D
a cc rI , copy thereof (Sec. 3800, Lab C.) CE 808(REV.8/81) APPLICATION FOR PERMIT
Policy ka. Company CP�s
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
tified cgpy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
d.+artment.
Date_47 dpplicant - <�'� '� FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPT ON FROM WORKERS
COMPENSATION INSURANCE ADDRESS :S s r,-CA �'� STATION � � � DEPTH �
(This section need not be completed if the work involved by the LOCALITY ,! t >L MANHOLE REFERENCE '0 UPPER
permit is for one hundred dollars ($100)or less.) `
I certify that in the performance of the work for which this CROSS ST. LG0i4G ' I TYPE OF CONNECTION LENGTH FROM
J�'+N Y. CURS P,I. M.L.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. e} t r ��/ P.C.No.
I p OWNER �r F�� • �;�. Y�"If:S C- caJc..��+r Com" CO.IMP.NO. JOB NO.
MAIL �y y - TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS p m "" `��� F=' ks` -b -
NOTICE TO APPLICANT: If, after making this Certificate of CITY t t 1' AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
Exemption, you should become subject to the Workers' LEGAL
f, L TEL.No.
Compensation provisions of the Labor code, you must forthwith DESCRIPTION
p p y DESCRIPTION l0T 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 PERMIT No.
LOT
SIZE OF LOT NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter SE OF y
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDIUNGS CHARGES
ness and Professions Code, and my license is in full force and
effect. CONTRACTOR i_2-j(,•i✓1t ck> ,'
> L %1Vf CONNECTION CHARGE FEE
[ f/��•y 0«
License Number
' LIC.Class F ADDRESS !J7~ FJ y i - REIMBURSEMENT FEE O
COnifaCiOr`'1``^-3 `- � `4afe '"�rt "' ��' yiTY ro y CC r DISTRICT NO. GROUP MAP PROCESSED BY
7 - TEL.NO. ?-i -( —C. e"S �' BK PG Z
❑ I am exempt under Sec. of the L.A.Co. STATE p CLLica I� (� ! 1 O
p LICENSE NO. �'.?�� s,.. E' - CLASS
Plumbing Code and/or Sec, of the NO DESCRIPTION OF WORK PE FINAL v
LU
HOUSE SEWER CONNECTING TO DATE �`° -VALIDATION a
B. & P. Code for the following reason PUBLIC SEWER 'y, �
SEPTIC TANK,SEEPAGE PIT OR Z
PITS AND/OR DRAINFIELD FINAL rte.
Date HOUSE SEWER CONNECTING TO BY . -
{' i� PRIVATE DISPOSAL SYSTEM
Signature )Lk��""`i g 0 - /'" CONNECT ADDITIONAL BLDG OR
OWNER-BUILDER DECLARATIO WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT DRAINHELD - t
I hereby affirm that I am exempt from the Contractor's License ExTN.,CESSPOOL,DRYWELL,MANHOLE
LOW for the following reason (Secton 7031.5, BUisness and Pro- ALTER,REPAIR OR ABANDON HOUSE}
fessions Cade): SEWER OR DISPOSAL SYSTEM r -
❑ 1,as owner of the property,or my employees with wages as 1�CCT.T
their sole compensation, will do the work and the structure 3W7
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNERS Permit $ 0 1 TTE
❑ 1,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE SC) TOTAL i 7044 ''`�-7 ."'50
licensed contractors to construct the project (Section ,
P I ( I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR,TO
Business and Professions Cade). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. - CHECK `?7i 50
CONSTRUCTION LENDING AGENCY CHANGE
h may- {{�
SIGNED THIS DAY OF j 19 , C•HANGE .(XI
I hereby affirm that there is a construction lending agency r--
OWNER OR ✓
for the performance of the work for which this permit is OWNERS AGENT ` -� 1,0_
slued (Sec. 3097, Civ. C.). ADDRESS Z'' .`' _ I; O«.I![71 6/19/39Lender's Name
Lender's Address
4045 3 AM u:G"t
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
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.
S gnatT ure of Perrnittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE