HomeMy Public PortalAbout6628 OAK AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm 4hat 1 have a certificate of consent to self 92iODD2 DPW 3187
insure, or a certificate.of Workers'Compensation Insurance, or 76A6440
a certified copythereof Sec. 3800, Leb-C ) � IICeos
Policy Not ,1117 company APPLI ATIOIwI FOR PERMITRM
IT
{ ❑ Certified copy is hereby furnished. SEWER e. SEWAGE DISPOSAL
❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department. cc��
Date 16-- ?"Y✓!Applicant/):A IRr!U ad's j3::a.rug- FOR APPLICANT TO FILL 1N CONNECTION DATA
CERTIFICATE OF EXEMPTION.FROM WORKERS' BUILDING f STATION DEP7Ff
COMPENSATION INSURANCE ADDRESS. Cs'0 2 Q Ave, �h t�Sd ii
(This section need not be completed if the work involved by the LOCALITY MANHOLE REFERENCE 'rte UPPER
permit is for one hundred dollars($100)or less,) v ER'
NEAREST f � y�� �j TYPE Of CO N LENGTH FROM
I certify that in the performance of the work for which this CROSS ST CI F Mf O 9(!;-�Li Y. =CURS P L.. M L TO P.L.
permit is issued, I shall not employ any person in any manner P.C.NO
so as.to become subject to the Workers'Compensation Laws: OWNER c1(;�!'L l� \If CO:IMP.NO. JOB NO.
MAILADDRESS v A
C� ��• F S j'¢ TRUNK PERMIT NO ROAD PERMIT NO.
Date Applicant Q�
JJ
NOTICE TO APPLICANT: If., after makingthis Certificate Of j j��s AFFILEGAL DAVIT WAIVER EASEMENT RECORD INSTR.NO. DATE
Exemption, you should become subjet to the Workers' CITY5%M b� TEL.No,
Compensation provisions of the labor code,you must forthwith I DESCRIPTION LOT NO HWY.OR ST WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK 'TRACT J f _ ,STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION r�O OF BLDGS'. PERMIT NO..
' SIZEOF LOT f . `�+'N01A1 ON LOT
I hereby affirm that I am licensed under provisions of Chapter USE OF r _ +' �� /r- �•-�'
9 (commencing with Section 7000) of .Division 3 of the Busi- BuILDINGs �:f?� �:i:4 C!?� CHARGES
ness and Professions Code, and my license is in full force and
effect. _ L CONTRACTORS t a .� �_ r. CONNECTION CHARGE FEE
license Number t Lic,Class . C-
.... n ADDRESS ! :REIMBURSEMENT FEE O
Contractor iijR�[�..111�'f Date /For L '� • st- r, r. DISTRICT NO. GROUP MAP' PROCESSED BY ()
- CITY f)f TEL.NO. .V,{" r2�T- JOT
BK PG s
❑ 1 am exempt under Sec. of the L.A.Co. LICENSE NO LI
} �� <' s
Plumbing'Code and/or Sec., of the NO. DESCRIPTION OFWORK FEE :FINAL W
HOUSE SEWER CONNECTING TO DATE VALIDATION
B. &P. Code for the following reason PUBLIC$EWER . y
.SEPTIC.TANK,.SEEPAGE PIT ORY
L � (� •) ,1
PITS AND/OR DRAWFIELD BY L�
Date.! r aa'�- HOUSE SEWER CONNECTING TO
<• .PRIVATE DISPOSAL SYSTEM.
Signature gLaa.zl r. � 14 CONN CT HOUSE SEAL BLDG OR
OWNER-BUILDIR DECLARATION WORKOVERFLOW SEEPAGE PIT,DRAINFIELD
L hereby affirm that I am exempt from the.Contractor's License EXTN.,CESSPOOL,DRYWELL.MANHOLE
Law for the following reason ($ecton.1031.5, Buisness,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 ;
is not intended or offered for sale (Section 7044, Business
and Professions Code). j OWNER'S Permit S
❑ I,as owner of the property,.am exclusively contracting with AUTHORIZATION TOTAL.FEE ,
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE'HEREIN NAMED CONTRACTOR TO.
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING:TO THE PUBLIC SEWER
CONSTRUCTION LENDING AGENCY I
I hereby affirm that there is a construction lending agency I SIGNED THIS. DAY OF 19_ 1
for the performance. of. the work for which 'this permit is OWNER OR
OWNERS AGENT
issued(Sec. 3097; Civ. C.). ADDRESS
Lender's Name
Lender's Address
I certify that I haveread 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 inspection purposes,
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE,