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HomeMy Public PortalAbout10648 OLIVE ST_Sewer__ WORKERS'COMPENSATION DECLARATION I rl 2�-5 I hereby affirm that I have a certificate of consent 4o self (1 /' VAI I 1 ' insure, or a certificate _of Workers'Cory anon Insurance, or 76A642D JJJ"`JJJ V l Policy,fi d Comp ny00, L L.E BOB(REV.B,eI, AP ICATION FOR PERMIT fff Policyst �CompanyT ©s ❑,.Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL Certified cgpy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY de tme .�, Date*1m _Applicant_( .J �-�- FADDR OR APPLIC NT TO FILL IN CONNECTION DATA t CE IFICATE OF EXEMPTION FROM WORKERS' ING COMPENSATION INSURANCE. ESS STATION '3 � DEPTH � (This section need not be completed if the work involved b the PPER y LITY _ l MANHOLE REFERENCE � LOWER permit is for one hundred dollars ($100)Or less.) LENGTH FROM NEAREST-- - TYPE OF CONNECTION I certify that in the performance of the work for which this sT. f y cuRe P L. MA TO P.L. permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. G P,C,No. ok& � CO.IMP.NO. � JOB NO, TRUNK PERMIT NO. ROAD PERMIT NO, Date Applicant ESS '�>W✓' - /, �I AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTICE TO APPLICANT: If, after making this Certificate of tEL.No.Exemption, you should become subject to the Workers' GALCompensation provisions of the Labor code, you must forthwith IPTION LOT NO. HWY.OR ST.WIDENING comply with such provisions or this permit sholl be deemed revoked. K - TRACT STATE ENCROACHMENT NO.OF BLDGS. PERMIT NO. LICENSED CONTRACTORS DECLARATION F LOT NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter F9 (commencing with Section 7000) of Division 3 ofthe Busi- INGS CHARGES ness and Professions Code, an. py license is in full force and effect. *13 CONTRACTO CONNEC71ON CHARGE FEE >- License Numbe 7 X '.�/ _Liic.Class ADDRESS REIMBURSEMENT FEE Contracto -' Dafe "' r— DISTRICT NO GROUP MAP PROCESSED BY u j CITY TEL NO. PG zLICENSE NO.m ❑ 1 am exempt under Sec. of the L.A.Co. STATE uC. j//{ry� @K � CLASS aj v r�� Plumbing Code and/or Sec. of the NO DESCRIP ION OF WORK FEE FINAL PUSE SEWER CONNECTING TO DATE VALIDATION a UBLIC SEWER /. + B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR Z PITS AND/OR DRAINFIELD FINAL ,Date HOUSE SEWER CONNECTING TO BY Signature PRIVATE DISPOSAL SYSTEM +1f g CONNECT ADDITIONAL BLDG,OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I am exempt from the Contractor's License EXTN,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Becton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSEI•. fessions Code): SEWER OR DISPOSAL SYSTEM ❑ I, as owner of the property,or my employees with wages as 7 ACCT.4 their sole compensation, will do the work and the structure "'Y;"" is not intended or offered for sale (Section 7044, Business 3•"J Y , and Professions Code). OWNERS Permit $ 1 ITEMS ❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE licensed contractors to construct the project Section 7044, TOTAL 27 . 50 p I ( HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO ���^f��I� Business and Professions Code), CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. tu�'FEC 27.50 { CONSTRUCTION LENDING AGENCY ;��� SIGNED THIS DAY OF 19_ ► �'Ht'lNG .00I hereby affirm that there is a construction lending agency t• for the performance of the work for which this permit is OWNER OR issued (Sec. 3097, Civ. C.). OWNERS AGENT ADDRESS �t.yyj }yy� .{{ Lender's Name � �( 1�° �i 8/24/89 Lender's�ddress 911 t F'M1;2,[15 I certif that i,,hb read this application and state that the above nzorrxtatio Is c ect. I agree to comply with all County ordin nde$,- tat ws regulating Plumbing and Sewe S, and �re'by au ori representatives of this Cou ty to en er U "' ab) me. ioned property for inspectio purpose . ,° ignot re f Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE I.