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Home My Public Portal About6374 OAK AVE_Sewer__ ,'VC;RR.S1_XkCOVI> NSArION DECLARATION 76AG420 APPLICATION FOR PERMIT CE 308 (2-80) I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL insure, or a certificate of Workers'Compensation Insurance,of rkf-,t I J�ic 3800t�ab F LOS ANGELES BUILDING AND SAFETY Policy No�i 4�37Y _,.,-PUNTY 0 C(mp Dy�� a certified N WC(rr a CO' N A S T-O TMA HOI-.-.R,.F. N Certified copy is hereby furnished. FOR APPLICANT TO FILL IN' CONNECTION DATA BUILDING STATION DEPTH RE -TY U_-LD Certified copy is filed with the county huAng in ADDRESS inspection UPPER t. C. A�, /' .� 1 �� MANHOLE REFERENCE LOCALITY LOWER TYPE rCO Date Applicant NEAREST I TYPE OF CONNECTION OINNECTION LENGTH FROM CROSS ST Y. CURB P.L. M.L. TO P.L. Cf"RTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE P.C. NO. OWNER ylgy IMP. NO. JOB NO. MAIL. (This section need not be completed if the Work involved ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO. >_ x"'C'e, by the permit is for one hundred dollars ($100) or less.) CL AF5=10AVIT WAIVER EASEMENTIRECORD. INSTR.NO.1 DATE 0 CITY NO, .3 1 certify that in the performance of the work for which this LEGAL pennit is issued, I shall not employ any person in any manner DESCRIPTION LOT NO. MW Y. OR ST. WIDENING so as to become subject to, the Workers'Compensation Laws. 0 BLOCK TRACT STATE ENCROACHMENT Date PERMIT NO. tit Applicant NO. 0 F BLDGS. NOTICE T L 0 APPLICANT: If, after making this Certificate of SIZV.-OF LOT NOW N LOT CL Exemption, you should become subject to the Workers' USE OF 0 BUILDINGS CHARGES Compensation provisions of the Labor Code, you must forth- with comply with such provisions or thispermit shall be CONTRACTOR CONNECTION CHARGE FEE deemed revoked, P REIMBURSEMENT FEE O_ LICENSED CONTRACTORS DECLARATION ADDRESS C, DISTRICT NO. GROUP A' .1 I hereby affirm that I am licensed under provisions of Chapter BK PG 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full force arid LICENSE N CLASS A effect, — S-Fil— WORK FEE: NO. DESCRIPTION HOUSE SEWER CONNECTING TO VALIDATION License Numbe1a4R6_z&_ Lic.Class PUBLIC SEWER DATE SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR GRAINFIELD Contracto4�" 0/&'4�Date HOUSE SEWER El CONNECTING TO BY PRIVATE DISPOSAL S'I am exempt from the licensing requirements as I am a M CONNECT ADDITIONAL BLDG.OR licensed architect or a registered professional engineer 3 WORK TO HOvsE ...ER acting in my professional capacity (Section 7051, Bus- OVERFLOW SCEPAnE PIT DRAiNFIELD iness and Professions Code). CXTN-'CESSPGO"'DRVW PIT, I—NNOLE ALTER,REPAIR OR ABANDON HOUSE _Jel, SEWER OR DISPOSAL S15T11 lAc.or Reg.No. Date— HOME OWNER-BUILDER DECLARATION I herebyR'S Permit S1 affirm that I am exenIpt from the Contractor's OWNERS —.1 1 License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE ness and Professions Code): I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- I RACTOR TO CONNECT THE ABOVE DESCR16ED EXISTING DWELLING as owner of the property, will do We work and the TO THE PUBLIC SEWER, structure is not intended or offered for sale (Section SIGNED THIS D Y 7044, Business anis Professions Code). OWNER OR OWNERS AGENT I-A CONS'TRUC'TION LENDING AGENCY AppREss- 2 60 I hereby affirm that there is a construction lending agency for the performance of the "Pork for miiich this perinit is issued(Sec. 3097,Civ.C.). Lender's Name— 14A.,11-0 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, and hereby authorize representatives of this County to enter upon the above-mentioned property for mspecti(�n purpo, S. SEE REVERSE FOR EXPLANATORY LANGUAGE J/ gignature of Permittee DaWl 0'