HomeMy Public PortalAbout10034 OLIVE ST_Sewer__ WORKERS'COMPENSATION DECLARATION
I heraby affirm that I have a cortificote of consent to self
insure, or a ce0ificate of Workers''ICompensatiort Insurance, or 76A642D
a certified copy thereof (Sec. 3800, Lab C..) 82-0002 DPW 6188 APPLICATION FOR PERMIT
Policy No. Company
Lertified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
[_I Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY d
department.
Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ADDRESS! ' tr '�a`." / STATION DEPTH
(This section need not be completed if the work involved by ther nANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY ..'f / LOWER
I certifythat in the performance of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROM
P CROSS ST. Y- CURB P L. M,I.TO P.I.
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 i.i F '* f CO_IMP.NO. JOB NO,
MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS f. " ,j ° Q
NOTICE TO APPLICANT: If, after makin this Certificate Of TEIc, AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
g CITY L.NO. i =P;"e.
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY OR ST.WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO.OF BLDGS- PERMIT NO.
SIZE OF LOT NOW ON LO?
I hereby affirm that I am licensed under provisions of Chapter USE OF
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS `iF } CHARGES
ness and Professions Code, and my license is in full force and
effect. CONTRACTOR '`'� . - �`a pY CONNECTION CHARGE FEE
License Number. Lic.Class ADDRESS REIMBURSEMENT FEE
DISTRICT NO. GROUP -MAP OCESSED BY
Contractor Date CITY TEL.NO - ? ' ) BK PG \`� F
cy kQ �
❑ I am exempt under Sec. _of the L.A.Co.
STATE
NO. CLASS r 0
Plumbing Code and/or Sec._ of the NO. DESCRIPTION OF WORK FEE FINAL
HOUSE
SEWER CONNECTING TO DATE Jy .7 �:,. VALIDATION
PUBLICB. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR FINAL _
PITS AND/OR DRAINFIELD
Date BY
HOUSE SEWER CONNECTING TO :11
PRIVATE DISPOSAL SYSTEM `° Q
Signature CONNECT ADDITIONAL BLDG.OR CC
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
Law for the fallowing reason (Secton 7031.5, BuisneSs and Pro- ALTER,REPAIR OR ABANDON HOUSE _.
fessions Code): SEWER OR DISPOSAL SYSTEM z
'as owner of the property,or my employees with wages as _ t t i
their sole compensation, will do the work and the structure / "' .- 7'
is not intended or offered for sale (Section 7044, Business 401
and Professions Code). NER'S Permit $
❑ 1,cps owner Of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE C: 27 00
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 .yB
SIGNED THIS i' DAY OF 19s
1 hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is OWNER
OWNERS AGENT
issued (Sec. 3097, Civ. C.).
ADDRESS
Lender's Name 1 (e Iia) to r
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 r gUlafing Plumbing and Sewers,
and P&by thorize pre enta ves of this County to enter
upont
th ab e endo r y for jr
spection purposes.
r
P ;
is Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE