HomeMy Public PortalAbout10048 OLIVE ST_Sewer__ i
WORKERS'COMPENS4TION DECLARATION
by"taffirm that I have'e'cerFtiM:ate of consent to self
1% certificate of Workers'Compensation Insurance, or 76A642D
a rt' 'o c°opy•xtherpf tsec�3B Lab C., E eoe(REV,„B3; APPLICATION FOR PERMIT
❑ ertified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
L"J Certified copy is filed with the county building inspect n COUNTY OF LOS ANGELES BUILDING AND SAFETY
department. — y%I
Date 6- 2 t p`�licant .f �--�-' � .> i` FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS'
BUILDING -
COMPENSATION INSURANCE ADDRESS e STA110N F /� DEPTH
�
✓ la lld ! l.�
(This section need not be completed if the work involved by1h LOCALITY ,.�.L r MANHOLE REFERENCE r IOPWER
permit is for one hundred dollars ($100)or less.) NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that in the performance Of the work for which this CROSS ST Y. CURB P.L. M L.TO P L.
permit is issued, I shall not employ any person in any manner
so as to become sub ect to the Workers'Compensation LOWS. ,�ss'em�' j P.C.NO.
1 p OWNE :'ye" _ CO.IMP.NO. JOB NO.
MAIL
Date Applicant ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO.
.�
NOTICE TO APPLICANT: If, after making cate Othis Certificate // d/ AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO DATE
CITY - TEL.NCr
i
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 ENCROACHM
LIU
LICENSED CONTRACTORS DECLARATION NO OF BLDGS. PERMIT NO.
SIZE OF LOT NOW ON LOT
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 / CHARGES
ness and Professions Code, and my license is in full force and
effect. CONTRACTOR CONNECTION CHARGE FEE
license Number-7---f-2 Lic.CIass ADDRESS f REIMBURSEMENT FEE
Contract r� ate !_, '" �' g
at-.� ' .��» - -p DISTRICT NO GROUP MAP ROC SSED BY dd O
CITY&- „ 3, L O. .. �... BK PG /r V
❑ I am exempt under SSTAfE LIC.
ec. Of the L.A.CO. LICENSE NO. CLAS •'� l/•
NO. D SCR TION OF WORK FEE c ;2 OF
Plumbing Code and/or Sec. of the FINAL V
f HOUSE SEWER CONNECTING TO DATE `4. VALIDATI N W
B. &P. Code for the following reason PUBLIC SEWER ) a
SEPTIC TANK,SEEPAGE PIT OR FINALgn PITS AND/CR DRAINFIELD
If Date - HOUSE SEWER CONNECTING TO BY �� !. - 12224
l 2 2 4 tt Z
,y. PRIVATE DISPOSAL SYSTEM G G.- f'!
Signature %` "� CONNECT ADDITIONAL BLDG OR /O • • • •
WNER-BUI ER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD p
I hereby affirm that I am 6zempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE ( • • J 850
Law for the following reason (Secton 7031.5, Buisnes5 and Pro- ALTER,REPAIR OR ABANDON HOUSE • * • 6 a J 0-05
fessions Code): SEWER OR DISPOSAL SYSTEM -
❑ 1,as owner of the property,or my employees with wages as 607-85
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permit $
❑ 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 CONTRACTO TO
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER,
CONSTRUCTION LENDING AGENCY SIGNEDTHISDAYOF �` 19_ ►
I hereby affirm that there is a construction lending agency OWNER OR
for the performance of the work for which this permit is OWNER;AGENT
issued (Sec. 3097, Civ. C.).
ADD
Lender's Name
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
011dinances and State laws regulating Plumbing and Sewers,
nd hsaeby authorize representatives of this County to enter
�Jp the obove-mentioned propefty for inspection purposes.
f >
i ature of P m ee Date SEE REVERSE FOR EXPLANATORY LANGUAGE