HomeMy Public PortalAbout6228 MUSCATEL AVE_Sewer__ F WORKERS' COMPENSATION DECLARATION � rell
I hereby affiM/That I have a certificate of consent to self E
insufe, or a mrtificate of Workers'Compensation?nsurance, or 76A642D
a certified copy thergof (Sec. 3800, Lab C > CE BOB(REV.B/BI' APPLICATION FOR PERMIT
Policy No.J//&6 Company is
�❑
certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
LJ (;entified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
deportment.
Date L- PP ant y � Z� FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING, STATION DEPTH
COMPENSATION INSURANCE ADDRESS S
(This suction need not be completed if the work involved by the /. MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY r__ G 4
NEAREST f ^� TYPE OF CONNECTION LENGTH FROM LOWER
I certify that in the performance of the work for which this CROSS ST. LCa Le" t 1 C% v. CURB P.L M.L.TO P.L >-
permit is issued, I shall not employ any person in any manner rr P.C.No.
6
so as to become subject to the Workers'Compensation Laws. OWNER E -r1.' %(7� IIJ I 1"J e-1 CO.IMP.NO. JOB NO.
MAIL -� TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS t7 IrE. �_
NOTICE TO APPLICANT: If, after making this Certificate of /t j}- �r AFFIDAVIT WAIVER EASEMENT RECORD INSTR.NO. DATE O
9 clrY C p7 rF l t t TEL No.
Exemption, you should become subject to the Workers' LEGAL alt
Compensation provisions of the Labor code, you must forthwith DESCRIPTION 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 PERMIT No.
LOT
SIZE OF LOT NOW ON LOT
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 CHARGES
ness and Professions Code, and my license is in full force and
effect. ,(` CONTRACTOR CONNECTION CHARGE FEE
{ryC y d }
License Number O fr+ [ Lic.Class ]�/ L REIMBURSEMENT FEE
ADDRESS ;.
CO tractor DISTRICT NO. GROUP MAP PROC.SSED BY
CITY. z��y TEL.NO. �}- � `�
STATE ^- �r ,p LIC. BK PG
91PIumbing
I am exempP under Sec. of the L.A.Co. ucENSE No. rJ�s^ �J CLAss - jq NO. DESCRIPTION OF WORK FEE Code and/Of Sec. of the - HOUSE SEWER CONNECTING TO FINAL
VALIDATION -
B. & P. Code for the following reason _ PUBLIC SEWER
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR DRAINFIELD FINAL
Date BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK OVERFLOO HOUSE SEWER ,
W SEEPAGE PIT,DRAINFIELD
I111 reby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWEL!,MANHOLE
La'for the following reason (Secton 7031.5, BuisneSs and Pro- ALTER•REPAIR OR ABANDON HOUSE
fe ions Code): SEWER OR DISPOSAL SYSTEM
I,as owner of the property,or my employees with wages as
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 TOTAL FEE
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
Business and PfOfe5S10nS Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY ,
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
OWNERS AGENT
sued (Sec. 3097, Civ. C:). ADDRESS
Lender's Name
Lender's Address
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,
anid hereby authorize representatives of this County to enter
Vpnn the above-mentioned property for inspection purposes.
Signature of Permit�e / Date SEE REVERSE FOR EXPLANATORY LANGUAGE