HomeMy Public PortalAbout5827 OAK AVE_Sewer__ 14, WORKERSJCOMPENSATION DECLARATION �j
20IX5tDPW 6/89
`f hereby affirm that I have a certificate of consent to self (�'
Insure or a certificate of Workers Compensation Insurance or 76A642D
a certified copy thereof (Sec 3800 Lab C , APPLICATION FOR PERMIT
Policy No Company
El Certified copy Is hereby furnished SEWER - 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 CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS FADDRESS
2 .4 A w STATION DEPTH
COMPENSATION INSURANCE /yY{� UPPER
(This section need not be completed If the work Involved by the G ' MANHOLE REFERENCE LowER
permit Is for one hundred dollars ($100)or less )I certify that in the performance of the work for which this NEAREST TYPE OF CONNECTION IENGTH FROM
permit is Issued 1 shall not employ any person In any manner LEGAL s T�,v� v cuRe P L M L ro P L
PC NO
so as to become subject to the Workers Compensation LOWS DESCRIPTION LOT NO CO IMP NO LOB NO
Date Applicant BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
NOTICE TO APPLICANT If otter makingthis Certificate Of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
MAP BOOK PAGE PARCEL
Exemption you should become subject to the Workers NO OF BLDGS
Compensation provisions of the labor code you must forthwith SIZE OF LOT NOW ON LOT HWY OR ST WIDENING
comply with such provisions or this permit shall be deemed USE OF
revoked BUILDINGS STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION OWNER T PERMIT NO
I hereby affirm that I am licensed under provisions of Chapter Te �J es Ke
9 (commencing with Section 7000) of Division 3 of the Busl MAIL Sp2 L CHARGES
ness and Professions Code and my license Is in full force and ADDRESS ii
effectCITY TEL NO Z SZD.S CONNECTION CHARGE FEE
License Number LIC Class REIMBURSEMENT FEE
CONTRACTOR
Contractor Date DISTRICT NO GROUP MAP PROCESSED BY
ADDRESS ® BK PG
❑ 1 am exempt under Sec of the L A Co
CITY TEL NO �Qa —3 a
O
Plumbing Code and/or Sec of the STATE LIC FINAL Q
LICENSE NO CLASS DATE VALIDATION z
B 8 P Code for the following reason NO DESCRIPTION OF WORK FEE O
HOUSE SEWER CONNECTING TO FINAL T �'
Date PUBLIC SEWER BY 1.T W
SEPTIC TANK SEEPAGE PIT OR
Signature PITS AND OR DRAINFIELD
OWNER BUILDER DECLARATION HOUSE SEWER CONNECTING TOPRIVATE DISPOSAL SYSTEM ► �7 21
I hereby affirm that I am exempt from the Contractor s License CONNECT ADDITIONALBLD 7��
Law for the following reason (Secton 7031 5 Buisness and Pro WORK TO HOUSE SEWER . f
fessions Code) OVEREXNFIOW CESS SEEPAGE
RLAINFIELD
MANHOLE �I
ElALTER REPAIR OR ABANDON HOUSE
I as owner of the property or my employees with wages as SEWER OR DISPOSAL SYSTEM
their sole compensation will do the work and the structure
Is not Intended or offered for sale (Section 7044 Business
and Professions Code)
❑ I as owner of the property am exclusively contracting with OWNERS Permit S
licensed contractors to construct the project (Section 704440
Business and Professions Code) AUTHORIZATION I TOTAL FEE Q
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
I hereby affirm that there Is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER
for the performance of the work for which this permit Is
Issued (Sec 3097 Civ C ) SIGNED THIS DAY OF 19_
OWNER OR
Lender s Name OWNERS AGENT
Lender s Address 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
and hereby uthorixe representatives of this County to enter
upon the ab me n pr erty for Inspection purposes
V Signat aNIN
me D tea SEE REVERSE FOR EXPLANATORY LANGUAGE