HomeMy Public PortalAbout6408 OAK AVE_Sewer__ ,WORKERS' COMPENSATION DECLARATION
I hereby affirm that 1 have a certificate of consent to self jI
inswe, or a certificate of Workers'Compensation Insurance, or "642 D U
a c Ifi c y thereof (Sec. 3800, L E ° hE „8APPLICATION FOR PERMIT
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❑ CCeE3rfi'ed copy is hereby furnished. SEWER - SEWAGE DISPOSAL
aCert'rfied copy is filed with the county buildin�Ispp�ection COUNTY OF LOS ANGELES BUILDING AND SAFETY
dep tme(IDate Kent ' FDESCRIPTION
OR APPLICANT TO FILL IN CONNECTION DATA
J CERTIFI 'ATE OF EXEMPTION FROM WORKERS' ING STATION If"% DEPTH
COMPENSATION INSURANCE ESS
(This section need not be completed if the work involved by the - MANHOLE REFERENCE -,J�;°� �� �'a UPPER
--TOWER
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permit is for one hundred dollars ($100)or less.) LITY ;
ST ,,✓' TYPE OF COtJ�7 N LENGTH FROM
I certify that in the performance of the work for which this sr y' Y, rr"CuRt P.L. M L TO P.L.
permit is issued, I shall not employ any person in any manner P C No.
so as to become subject to the Workers' Compensation Laws. R CO IMP.NO. JOB NO.
MAILESS+"`,�.".'� --�� TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant
NOTICE TO APPLICANT: If, after makingthis Certificate Of "T" EASEMENT RECORD INSTR.NO DATE
+ TEL O.Exemption, you should become subject to the Workers' ALCompensation provisions of the Labor code, you must forthwith IPTION LOT NO. HWY OR ST WIDENING
comply with such provisions or this permit shall be deemed
revoked. TRACT STATE ENCROACHMENT
NO.OF BLDGS. PERMIT NOLICENSED CONTRACTORS DECLARATION �`F LOT NOW ON LOTfI hereby affirm that I am licensed under provisions of Chapter F --"""' , ", P;3 r`'d �3
9 (commencing with Section 7000) of Division 3 of the Busi- INGS �` W CHARGES
ness and Professions Code, and my license is in full force and _ _
effect. CON7RACT0 '� -� �/� CONNECTION CHARGE FEE
License Number ' ! C�s C7- '"' 7—P" e-"
� ADDRE .�T. .+ _ BURSEMENT FEE
Cantrac f y y a DISTRICT NO. GROUP MAP PRQOSSED BY
_ y 'G' "y Y, - 4f {-�7 �-,_: CITY ../' '^ �`' .af '�'ri'�= ;7'�' 7 1 [,-. BK PG / 0
❑ f am exempt under Sec. of the L.A.Co. LICENSE NO.. `� f. +' CLASS ��_
J O ll.✓✓ �
Plumbing Code and/or Sec. of the NO. DESCRI ION OF WORK FEE FINAL O
HOUSE SEWER CONNECTING TO DATE •! 1_
B. & P. Code for the following reason PUBLIC SEWER VALIDA�, N W
SEPTIC TANK,SEEPAGE PIT OR Q.
PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO V/ /' Z
PRIVATE DISPOSAL SYSTE ✓
Signature CONNECT ADDITIONAL BLDG.OR ,
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
I hereby affirm that I am exempt from the Contractor's License OVERFLOW SEEPAGE PIT,DRAINFIELDEXTN.,CESSPOOL,DRYWELL,MANHOLE
Low for the following reason (Secton 7031.5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work and the structure # • • a • �
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNERS Permitg `° l 1 • • (j
❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE • •
licensed COntrtlCT01S TO construct the project (Section 7044, 5 0 I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO L
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER
0 l 5-86
CONSTRUCTION LENDING AGENCY ,
I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_
for the performance of the work for which this permit is OWNER OR
issued (Sec. 3097, Civ. C.). OWNERS AGENT 4 R A
ADDRESS
Lender's Name �} • a e • 1 Q
Lender's Address + • •
I certify that I have read this application and state that the 27. 5 0
above information is correct. I agree to comply with all County y
ordinances and State laws regulating Plumbing and Sewers, 2
• • ° 7_5;0 6
and hereby authorize representatives of this County to enter
upon t above-mentioned Operty for inspectionurposes. 4, ! 5' 8 6
Signature of Pe ittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE