HomeMy Public PortalAbout10057 OLIVE ST_Sewer__ WORKERS'CO:MPENSATTON DECLARATJON 76A642t1 PP ICATI N FOR PERMIT
s. .T CE 808 (2-80)
I hereby'af'frrin tat I have a certificate of consent to pelf CJ EWER,-SE V E p I SJ P07,
insure,or a certit;,itr ofWorkers'Compensation InSirranCc,or
a certified copy theieof(Sec. 3800,Lab. C.) COUNTY OF LOS AN`Oa BIJ ND SAFETY
Policy No. Company._ 'ELE� „� ---
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN COQON TA
; BUILDING ,� �.d"' 5T.,ION DEPT
Qed rofied copy IS filewith the county building inspection Ab DR ESS `,�' 6� �j _ ' _ _ UPPER
j`rart-mens. 1,IANHOLE REFERENCE.
LOC AL IT"r .,.., •k—ty'1-�– LOWER
Date_—. Applicant—
NEAREST — �"� v TYPE OF CONNECTION LENGTH FROM
CR'O85 3T.
nv.RTII'IC.ATI> EXEMPTION y- CURB P.L. M.L. TO F.L.
Ey} &1205,4 - -- - - # -- -- _--
R
COMPENSATION INSURANCE /,( P.C. NO.
OWNER ,I (bS 4 �'A C;`�'' �' CO. IMP. NO. JOB NO.
MAIL / r I
hp,
section need not be completed if the work involved ADDRESS � �f ! P-1
hp, 47
TRUNK PERMIT NO. ROAD PERMIT NO.
the permit is for one hundred dollars (51011) or less.) E'
� (DAVIT WAIVER EASEMENT RECORD. INSTR.F0. PATE C3
CITY NO. of "
I tt rtify that in the perfornriance of the work for which this LEGA '
pmit is issued, I shall not employ any person in any manner DESCRIPTION LOT NO. HW , OR S . WIDENING 0
s . s to become subject to the Workers'Compensation Laws. �--�-� — - _ 0
I
as BLOCK TRACT STATE ENCROACHMENT Ll.t
e — ON
Applicant NO.. OF SLOGS. PERMIT NO. Q
LOT
N�TIC}: TC) APPI:ICANT: if, after making this Certificate of SIZE OF LOT NOW
E,Xemption, you should become subject to the Workers' USE OF
Compensation provisions of the Labor Code, you must forth- BUILDINGS CHARGES—
with comply with such provisions or this permit shall be CONTRACTORCONNECTION CHARGE FEE
deerned revoked. -
LICENSED CON'TRAC TC)RSI DCLAIkATICyN ADDRESS A r REIMBURSEMENT FEE
NO. .
I jereUs' affirm that I am licensed under provisions of Chapter CITY TEL. NO.
DISTRICT GROUP MAP PRO F_ ED BY
PG
9 Il co nmencing with Section 7000) of Division 3 of the flusi r� RK'
STATE LIC.
enessffect.
anu Professions Code, and my license Is in full force and f ;71"
LICENSE NO. CLASS
ef'fCl"t' NO. DESCRIPTION OF WORK FEE
HOti SE SEWER CONNECTING TO FINAL _ - VALIDATION
L ense Number LIC.Class ___ PUe C SEWER DATE
SEPTIC TANK,SEEPAGE PIT OR
- PIT A.NO IDR RAINFIELDi ntractor -~ - Date__- -
FINAL
I DIS.,C: S�.W EF? CDNNECTIN6 rC'I �
PRIVATE DISPOSAL SYSTEM
I ant exempt from the iicensing requirements as I am a �c:DNN Et.T ADOIT I9 NAL BLDG:.OR ",lb -
��� Incensed architect Or a registered professional engineer WORK TO HOUSE SEWER
acting in mV professional capacity (Section 7051, BuOVERFLOW SEEPAGE PIT,DRAINFIELD
iness and Professions Code). TLINE. CESSPOOL,DRYw=_LL,NOUS OLE
ALYE R,RE PRIW OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
c.or Reg.No.___. Date _
140ME OWNER-BUllA)FR DECLARATION
epf'h reby affirm that I am exempt from the Contractor's
OWNER'S Permit s :
cense Law for the. following reason (Section 7031.5, Busi- AUTHORiZATION TOTAL FEE �
Ass and_xcTfessions Code):
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMEp CON-
TRACTOR TO CONNECT THE ABOVE OESCRIHE'D EXISTING DWELLING
I, as owner of the property, will do the work and the TO THE PUBLIC SEWER.
structure 15 not intended or offered for sale (Section SIGNED THIS DAY OF 29
I
'7044, barslness and Professions Code). OWNER OR
OWNEiQS ACi E7aT
CONSTRUCTION LENDING AGENCY wppRess
I h=iL'.Jy affirm that there is a construction lending agency --- ---"-`� --'----
fol _ne performance of the work for which this permit is
issue;(See. 3097,Civ.C.).
Lender=s Name-_ —.
Lep tder's Address
Icettif that I have read thi% 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 represent_Itives of this ('•0unty to enter
upon the above-mentioned pioperty for inspection purposes,
n j SEE RFVEJ,'SE FOR.EXPLANATORY L_A_.N(=t_'AGI' - .
7ignature of Permittee Date