HomeMy Public PortalAbout6396 OAK AVE_Sewer__ WORKERS' COMPENSATION DECLARATION 20
'N I hereby offirrp that I have a certificate of consent to self 16A642 DPW 6789
insure. or a certificate of Workers' Compensation Insurance, or A642D
C,
certified copy thereof (Sec. 3800, lab C ) APPLICATION FOR PERMIT
Policy No_._ _Company-.-
❑ Certified cagy is hereby furnished. SEWER - SEWAGE DISPOSAL
F] Ce.tified 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' :aiL.DING s
COMPENSATION INSURANCE A� DRESS -° � �( STATION DEPTH
(This sect:,),, need not be completed if the work Involved by the �a MANHOLE REFERENCE UPPER
permit .s for one hundred dollars ($100)or less.) >enuTr 4.. L LOWER
t' AREST TYPE OF CONNECTION, LENGTH FROM
I certif, that in the performance of the vork for which this cHossST L Q I7. CURB PL M 1 TO P L
permit is slued, t shall not employ any person In any manner LEGAL
so as tc :ecome subject to the Workers' Compensation Laws. DESCRIPTION LOT NO P c NO
CO IMP,NO LOB NO
DateBLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
. Applicant
NOTICE TO APPLICANT: If, after making this Certificate of ASSESSOR q^� l AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
a MAP ESOOK (� 4—� PAGE (,� PARCEL C p
Exemption, you should become subject to the Workers' NO OFBLDOS.
COmper,:-olion provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT HWY OR ST WIDENING
comply „voh such provisions or this permit shall be deemed ,SSE OF
revokec RUIi DI NGS STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATIONrkj
PERMIT NO
I hereby affirm that i am licensed under provisions of ChapterOWNER , ��
9 (commencing with Section 7000) of Division 3 of the Busi- MAIL
ness and Professions Code, and m}/license is in full force and ADDRESS -r m CHARGES
effect. -TTY TEL.NV. .z L.y CONNECTION CHARGE FEE
License Number _.Lic. Class REIMBURSEMENT FEE
CONTRACTOR
ContrOCIot Date DISTRICT NO GROUP MAP PROCESSED 8Y
ADDRESS
1 am exempt under Sec. of the L.A.Co. f11 BK PG
0.
CITY TEL No. :,� � � z- -- ri"lR'r r e-.�'-° O.
Plurnbing Code and%ar Sec.----cif the STATE LIC FINAL Cy
LICENSE NO, CLASS DATE r` VALIDATION Z
B. & ° Code for the following reason NO. DESCRIPTION OF WORK FEE O
HOUSE SEWER CONNECTING T. FtNAl ►-
Dote L:BL'C SEWER - BY _ a `•.•'," k. (,)
SEPTIC TANK SEEPAGE PIT ORUJ
Signature PI'S AND OR DRA NFIE,D y C y s
OWNER-BUILDER DECLARATION HOUSE SDISP CONNECTING NG r0 oil.
e� t` z
PRIVATE Ut5PO5Al SYSTEM �6 --
hereby affirm that I am exempt from the Contractor's Lic Erl4e CONNECT ADD TIONAL BLDG OR 1 1�.,
Law for the following reason (Sectors 70;31.5, Buisness and Pro- WORK TO HOUSE SEWER
fessions Code): OVERFLOW SEEPAGE PIT DRAINFIELD ''IY# 15 :L - -75
EXTN CESSPOOL DR�WEIL MANHOLE AL
1,CIS owner of the property, ar my employees with wages as 1 SE SETERWER OO PAIRR p15PO ABANDON HOUSE •e
a SAL SYSTEM � 4 +"! 1+7E
`�-
their sole compensation, will do the work and the structure
isnot intended or offered for sole tSection 7044, Business
and Professions Code).
] I,as Owner of the property, am exclusively contracting with
hcenseed contractors to construct the proiect (Section 7044, OWNER'S Permit $
Business and Professions Code). AUTHORIZATION TOTAL FEE '> °-; gl`�f= 'ff "
CONSTRUCTION LENDING AGENCYHAVE AT THIS ^SATE A COr IKACT W H THE HEREr NAMED CON7RACTOQ TCS � AM 9-- r,t.
7
'
I heri affirm that there Is a construction lending agency CONNECT THE A8Cvf DESCRIBED Ex,ST!NG:;wEL,ING TC. ,,F P;B. SEWER
for the performance of the work for which this permit Is PON.
Issued (Sec. 3097, Civ, C.). c,',GNED TH)5 DAY OF
WNER OR
Lender's Name :i'WNERS AGENT
Lender's Address _
7GRES5
1 certify that I f.ove read this application and state that the
above inicrr,Tation is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers,
and heret:'y outhorize representatives of this County to enter
upon the cbove mentioned property for i,nspecttg n pZz"le
sS.
Ig aft ,f Permute Dare ( SEE REVERSE FOR EXPLANATORY LANGUAGE