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WORKERS COMPENSATION DECLARATION CE 3 5-5-
808 D APPLICATION P L I CATION FOR PER I {�
CE 808 moo) L J
I hereby affirm that I have a certificate of consent to self - SEWER-SEWAGE DISPOSAL
Innsu,'r�e o certificate of Workers Compensation Insurance or
ag; ther A �b C , _ COUNTY OF LOS ANGELES BUILDING AND SAFETY
Polic o �(i
ertified copy is hereby furnished FOR APPLICANT TO FILL IN CONNECTION DATA
BUILDING � 0 STATION DEPTH
Certified copy is filed Ith the ounty building Inspection ADDRESS � ,� UPPER
d rim nt LOCALITY MANHO REFERENCE
LOWER
Date ` p Ilcant NEAREST 'r-
C. TYPE O ONNECTION LENGTH FROM
CERTIFICATE OF EXEMPTION FRO ORKERS oss sr r B P L M L TOP L
COMPENSATION INSURA CE PC No
OWNER CO IMP NO JOB NO
MAIL
(This section need not be completed if the work involved ADDRESS TRUNK PERMIT NO AD PERMIT NO a
by the permit is for one hundred dollars ($100) or less) AFFIDAVIT I WAIVER EASEMENT RECO: INSTR NO I DATE O
CITY TEL NO ()
I certify that in the performance of the work for which this LEGAL
permit is Issued I shall not employ any person in any manner Dfi SCR I PTION LOT NO HWY OR ST WIDENING
so as to become subject to the Workers Compensation Laws 0
BLOCK TRACT STATE ENCROACHMENT V
PERMIT NO
Date Applicant NO OF SLOGS �+ d
NOTICE TO APPLICANT If after making this Certificate of sizE of Lor NOW ON LOT to
Exemption you should become subject to the Workers USE OF
Compensation provisions of the Labor Code you must forth BUILD( S CHARGES Z
with comply with such provisions or this permit shall be CONNECTION CHARGE FEE
deemed revoked CONTRACT
REIMBURSEMEN
LICENSED CONTRACTORS DECLARATION RO
ADDRES j
I hereby affirm that I am licensed under provisions of Chapter DI•rwICT No GUP MAP PROCESSED Br
9 (commencing with Section 7000)of Division 3 of the Busi
CITNo d v BK PG
ness and Professions Code and my license is in full force and STATE LIC
effect LICENSE NO CLASS
NO DESC IP ON OF FEE
,. /� HOUSE SEWER CONNECTING TO FINAL V (DATION
ALice Number c Class G PUBLIC SEWER DATE �•"�
/� SE TIC TANK SEEPAGE PIT OR
QDate ' PITS AND/OR ORAINFIELD
FINAL
HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
I am empt from the licensing requirements as I am 8 CONN ECT ADDITIONAL BLDG OR
licens d architect or a registered professional engineer WORK TO HOUSE SEWER
acting in my professional capacity (Section 7051 Bus OVERFLOW SEEPAGE P T DRAINFIELD
mess and Professions Code) EX CESS OOL OR r IN LL MANHOLE
ALTER REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
Lic or Reg No Date
HOME OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors OWNERS Permit II /os-0
;96467A
License Law for the following reason (Section 7031 5 Busl AUTHORIZATION TOTAL FEE
ness and Professions Code) I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON # • • • • 1 0
I as owner of the property will do the work and the TO THE ORUBLIC SEWER THE ABOVE DESCRIBED EXISTING DWELLING 1
structure is not Intended or offered for sale (Section SIGNED THIS DAY F Is • • G 1 5
7044 Business and Professions Code) OWNER OR �.�
OWNERS AGENT • • 0215006
CONSTRUCTION LENDING AGENCY '
wooRess
I hereby affirm that there is a construction lending agency 0927-82
for the performance of the work for which this permit is
issued(Sec 3097 Civ C)
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 Courty
ordinances and State laws regulating Plumbing and Sewers
and hereby authorize representatives of this County to enter
on the above mentioned pr erty for nspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
1gnat of Permittee or Date