HomeMy Public PortalAbout10638 OLIVE ST_Sewer__ (3) WORKERS' COMPENSATION DECLARATION �1
I hereby affirm that 1 have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or eA642D
a certifiedlwey. h. r (Sec. 3800, gab C.) f I E 808(REV B,el) APPLICATION FOR PERMIT
Policy No.— .z. ` ompany E f�EY1 e:sx.ti f a C.t!,. s
El Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
Certified copy is filed with th county building inspec* n COUNTY OF LOS ANGELES BUILDING AND SAFETY
depar ent I e
Date ^Applicant tf FOR APPLICANT TO FILL IN CONNECTION DATA
CE TIFIC TE OF EXEMPTION FROM WORKERS'
BUILDING OMPENSATION INSURANCE ADDRESS , _ STATION _.c DEPTH
(This section need not be completed if the work involved by the LOCALITY MANHOLE REFERENCE -y C�/D°�. UPPER
� y -'t' `' _ (i�' LOWER
permit is for one hundred dollars ($100)or less.)
NEAREST I ✓ j a f TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. / � (. %- _> �''� Y. CURBP.L. MATO P.L. !�
permit is issued, I shall not employ any person in any monner 1 ' PC. NO. t!
so as to become subject to the Workers'Compensation Laws. OWNER o Co IMP.NO. X08 No. U
MAIL
ADDRESS o ��• �' �RMIT NO. 57 ROAD PERMIT NO. W
Date Applicant a+1
NOTICE TO APPLICANT: If, after makingthis Certificate of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE O
CITv ,�.r�7,-�' - -a EL No "� :✓i%?r �
Exemption, you should become subject to the Workers' LEGAL tzU
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 c
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 yy �y
effect. CONTRACTOR Ci « c.•� �.,!� Aa CONNECTION CHARGE FEE
License Number Lic,Class ADDRESS t (.CJ e C REIMBURSEMENT FEE
ff 'a: DISTRICT NO. GROUP MAP - PROCESSED BY
Contractor Date CITY /7/ k". g-.s(.- r "�?' TEL.NO. v _
BK PG
STATE j` UC.
❑ I am exempt under Sec. - of the L.A.Co. LICENSE NO. -1w 7 CLASS -
NO. DESCRIPTION OF WORK FEE
� 6 r
Plumbing Code and/or Sec. of the HOUSE SEWER CONNECTING TO ^� DA EL g 7 VALIDATION
PUBLIC SEWER 'i '•` �'a""
B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR FINAL ...� 7
PITS AND/OR DRAINFIELD
Date BY
HOUSE SEWER CONNECTING TO r ,'�? '-• , 4,a.,
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR
ss
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER ► ���/
OVERFLOW SEEPAGE PIT,DRAINFIELD L
I hereby affirm that I am exempt from the Contractor's license EXI-N.,CESSPOOL,DRYWELL.MANHOLE
Low for the following reason (Secton 7031.5, 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). OWNER'S Permit $ ^- F1
❑ 1,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 NAM€ CO AC OR TO
Business and Professions Cade). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY
I hereby offirm that there is a construction lending agency SIGNED THIS DAY OF 19_
for the performance of the work for which this permit is OWNER A
P P OWNERS AGENT_
issued (Sec. 3097, Civ. C.). AODRE%s
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
ordinances and State laws regulating Plumbing and Sewers,
and reby authori<-e re sentatives of this County to enter
e abov me do ro rt for ins ection ur Os g011 a �r
up n41
t property Y P P p
gLd�,e'� �. I "� �, t ..a " t t
5
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE