HomeMy Public PortalAbout5833 OAK AVE_Sewer__ WORKERS COMPENSATION DECLARATION D
CE 808(2 80) APPLICATION FOR PERMIT {�
CE 808 (J
I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL
insurt Or a certificate of Workers Compensation Insurance or
ed there f ab COUNTY OF LOS ANGELES BUILDING AND SAFETY
oil No
Certified copy is hereby furnished FOR APPLICANT TO FILL IN CONNECTION DATA
BUILDING STATION �/} DEPTH '
ADDRESS 3 V v
I Certified copy B filed with th ounty building Ins2�4'
UPPER
depart ent MANHOLE REFERENCE_ LOCALITY LOWER
e plicanNEAREST TYPE OF TION LENGTH FROM
CERTIFICATE OF EXEMPTION F M WORKERS cRoss ST Y URB P L M L TOP L
COMPENSATION INSU ANCE P C No
OWNER CO IMP NO ! JOB NMAILO
(This section need not be completed if thework involved ADDRESS TRUNK PERMIT NO ROAD PERMIT NO
by the permit is for one hundred dollars ($100) or less) r pF PIDAV T WwrvHR EASEMENT RECORD INSTR NO DATE
CITY TEL NO V
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 DESCRIPTION LOT NO I WY OR ST WIDENING 0
so as to become subject to the Workers Compensation Laws H
BLOCK TRACT STATE ENC
ROA V
Date Applicant NO of BLOCS - r W
PERMIT NO
NOTICE TO APPLICANT If after making this Cer ificate of SIZE OF LOT NOW ON LOT N
Exemption you should become subject to the Workers USE OF CHARGES Z
Compensation provisions of the Labor Code you must forth BUILDIN -� _
with comply with such provisions or this permit shall be CONNECTION CHARGE FEE
CONTRALTO
deemed revoked REIMBURSEMENT FEE
LICENSED CONTRACTORS DECLARATION ADDRESS
I hereby affirm that I am licensed under provisions of Chapter DISTRICT NO GROUP MAP PROCESSED BY
PC
9 (commencing with Section 7000)of Division 3 of the Bust CI L No /�
ness and Professions Code and my license is in full force and STATE ,/ Llc Q LK �/
effect LICENSE NO Y� CLASS y /TTsv
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECT NG TO '� FINAL _�.y VALIDATION
License Numb�J✓� Lic Class uBLIC SEWER DATE —L/J
p� �i SEPT C TANK SEEPAGE PIT OR
Con / ate ���— O PITS AND/OR DRAINFIH LO
HOUSE SEWER CONNECTING TO BY
❑ PRIVATE D SPOSAL SYSTEM
I am a mpt from the licensing requirements as I am a A
CONNECT ADDITIONAL BLDG OR
licensed architect or a registered professional engineer WORK TO HOUSE SEWER
acting In my professional capacity (Section 7051 Bus OVERFLOW SEEPAGE P T GRAINFIELD
mess and Professions Code) ExTN CESSPOOL DRYWELL MANHOLE
ALTER REPAIR OR ABANDON HOUSE
SEWER OR D SPOSAL SYSTEM
Lic or Reg No Date
HOME OWNER BUILDER DECLARATION z 4 9 6i 0 A
I hereby affirm that I am exempt from the Contractors OWNERS �Permi�t �SLicense Law for the following reason (Section 7031 5 Bust AUTHORIZATION # • • • •
ness and Professions Code) y
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON 2 002250
1RACTOR TO CONNECT THE ABOVE DESCRIBED E% TING D E N
I as owner of the property will do the work and the TO THE PUBLIC SEWER
structure is not intended or offered for sale (Section SIGNED THIS DAY OF -�1-� _ • °I B 2 2 5 0 5
7044 Business and Professions Code) OWNER OR _
OWNERS AG 017 4-82
CONSTRUCTION LENDING AGENCY AD 1 1
I hereby affirm that there Is a construction lending agency
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 1 agree to comply with all Courty
ordinances and State laws regulating Plumbing and Sewers
and hereby authorize representa ves this County to enter
pon the above mentioned p per y f Inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE \
Signatur f Permittee Date {