HomeMy Public PortalAbout10152 OLIVE ST_Sewer__ WORKERS' COMPENSATION DECLARATION
T ZD-0051 DPW 6180
t he by affirm that i have a certificate of consent to self
msL>� a/ a certificate of Workers' Compensation Insurance, or 76A642D n pip p
J cerrtfied Opy thereof (Sec 3900, Lob C. APPtklCATJ�N FOR PERMIT
Policy No.��n..r2�Company�`' �----
❑ Certified copy Is hereby furnished / SEWER. - SEWAGE DISPOSAL
Certified copy is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Date__. __.Applicant \ ;+ � FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING -
COMPENSATION INSURANCE ADDRESS ', - ., DEPTH
(This se on need not be completed if the work involved by the n3.ANHOLE REFERENCE '� ;� jam
permit is r one hundred dollars ($100)or less.) LaGAurY r. LOWER
certify tha in the performance of the work for which this NEAREST �y TYPE CONNECTION LENGTH FRO
V p O CROSS 5T. �' - °E1 CURB P L ;+"' h1 L TO P L
permit is issue I shall not employ any person In any manner
so as to becom -rub ect to the Workers' Compensation Laws. DESCR-LEGAL
LOT NO. :-JO P C NO
I p MF NO CB NO
BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
Date ARphcant __
NOTICE TO APPLICANT; If, after makingthis Certificate Of ASSESSOR ' AFHDAWT WAVER EASEMENT RECORD INSTR NO DATE
MAP BOOK PAGE PAR4EL
Exemption, you shauld:, become subject to the Workers' NO OF BLDGS
Compensation provisions n{the Labor coder you must forthwith StzE OF LOT NOW ON LOT
HWv OR St WIDENING
comply with such provisions Or this permit shall be deemed USE of
revoked. '3 BUILDINGS - STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION PERMIT NO
�� ���
I hereby affirm that I am licensed under provisions of Chapter OWNER -I ` l -I j _�_f)
9 (commencing with Section 7000) of Division 3 of the Busi- MAIL .• -
ness and Professions Code, and mJ license is in full force and ADDRESS ]. CHARGES
effect. ' 'CITY
TEL.NO �> .,� sJ' CONNECTION CHARGE EEE
_r . - 7 -
License Number iii" _-_Lic. Class '�I
q p RE,MBURSEMEN7 FEE
C CONTRACTOR y ; DISTRICT NO GROUP MAP PROCESSED BY
r -- ADDRFSS L.\C"iN ✓ 6K PG ! -
LJ I am exempt under Sec. of the L A. Co.
(11T`f TEL.NO C •- -.� .- ^' �+ �
Q.
Plumbing Code and/or Sec.i of the STATE LTC >- .NAL s=' > ':a
LICENSE NO j CLASS - ATE VALIDATIONS Z
B. & P. Code for the following reason NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONN€C"NG TO r"JAL
Date PUBLIC SEWER rfr B w
SEPTIC TANK SEEPAGE PIT OR
Signature _a'a �-^ � PITS AND OR DRAINFIELD
HOUSE SEWER CONNECTING TO
OWNER-BUILDER DECLARATION PRIVATE DISPOSAL SYSTEM ,
I hereby affirm that I am exempt from rhe Contractor's License CONNECT ADDITIONAL BLDG OR
Low for the following reason (Section 7031.5, Buisness and Pro- WORK TO HOUSE SEWER T
fessions Code): OVERFLOW SEEPAGE PIT DRAINFIELD _
EXTN.CESSPOOL DRYWELk, MANHOLE
Ci "'w•-�• ,
I,as owner of the property, or my employees with wages as ATTER REPAIR OR ABANDON HOSE
;EWER OR DISPOSAL SYSTEM
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business
t
and Professions Cade). t
L, 1, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Section 7044, OWNER'S Permit $
Business and Professions Code). AUTHORIZATION TOTAL FEE
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRA;T WITH THE HERE nI NAMED ;;NTRACTOR T;;
I hereby affirm that there is a construction lending agency CONNECT tHE ABOVE DESCRIBED FxISTING D: