HomeMy Public PortalAbout9041 OLIVE ST_Sewer__ �, `�,%WORKEN ',SGOMPHNSATION DECLARATION ;
i.�� ner by al
fir'�p that I have a certificate of consent to self
I� sure,or a certificate of Workers'Compensation Insurance, or 76M420
a certified cgPy thereof(Sec. 3800, Lob C.) CE6Q8(FEV 1701• PPLICATI®IVd. FOR PERMIT
Policy No:�Company, I,
❑ 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 PROM WORKERS' BUILDING STATION DEPTH
COMPENSATION INSURANCE ADDRESS C-• OLIVE 5 1
(This section need not be completed if the work involved by theLOCALITY S T MANHOLEAEFERENCE UPPER
PP ERR
permit is for one hundred dollars($100)or less.:):
I certify that in the performance of the work for which this C p55 EST
(� c A TYPE OF CONNECTION LENGTH FROM
R�V� •LeY. CURB P L. M.L.TOP L.
permit is issued, I shallnot employ any person in any manner
so as to becomesubject-to the Workers'Co pensation Laws. ^TT OWNER E t1 i�9 CO.IMP.No. OB NO..
Date ( ppliCant .[o-f ADDRESS /-{ l; .�f.,, v MAIL TRUNK:PERMIT NO ROAD PERMIT NO.
NOTICE TO APPLICANT.- If, ofte mak.in this Certificate ot" _ �y Q-7 p -7 AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE:
9 CITY i�iz?PC.i' e174TEL,No. (g �!3 f.�07 f
Exemption, you should beco .e -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 ENCROACHMENT
LICE.NS.ED CONTRACTORS.DECLAR.ATION NO OF eLI0S. PERMIT No.
I hereby affirm that I am licensed under provisions of Chapter USE OF NOW ON LOT
y p P 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: CONTRACTORS U"SKa g-EN3 to CONNECTION CHARGE FEE
License Number Lic,Class ADDRESS C4 Q LI V e REIMBURSEMENT FEE.
Contractor Date �7 p DISTRICT NO, GROUP MAP PROCESSED By
CITY i l f'" �r 1.NO /g . '�
El am exempt under Sec. of the L:A.Co. PG
STATE LIC. �q 0
P LICENSE NO C1A55 '�L or "(
Plumbing Code and/or Sec.. of the DESCRIPTION OF WORK FEE FINAL U
FIQUSE
SEWER CONNECTING TO DATE VALIDAT N. KM
B. &P. Code for the following reason PUBLIC
SEWER
SEPTIC TANK,SEEPAGE PIT OR. FINAL
PITS AND/OR DRAINFIELD
Date HOUSE.SEWER CONNECTING TO .BY m
PRIVATE DISPOSAL SYSTE
Signature CONNECT ADDITIONAL BLDG..OR /
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,D.RAINFIEL.D
I hdreby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE 1�
Low for the following reason(Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code); SEWER OR ISPOSAL SYSTEM -3 O 2 9.4 A
as owner of the property,or my employees with wages as # o. 0 0 0 0 8
'
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 St o o.2 j,5 U
❑ J,os owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE I a q
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRAL70R TO o 0 o C !,J 10Business-and Professions Code), CONNECT THE ABOVE DESCRIBED EXISTING DWELLING.TO THE.PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY I. 2 5_ 5
I hereby affirm that there is a construction lending agency SIGNEDTHIS. DAYOF -19_
for the performance of the rk for which this permit. is OWNER OR
OWNERS AGENT
issued(Sec. 3097; C.). ADDRESS.
Lender's Name c7
Lender's Address
i
1 certify that I have :read this application and state that the j
above Information is correct. I agree to comply with all County I
ordinances and State laws regulating Pfumbing and Sewers, t
and hereby authorize representatives of this County to enter l
uPon th. above-m Honed property forr inspection purposes. / �+
+.r�r tIGSJ
ti Si tura of Permi fee Date SEE REVERSE FOR EXPLANATORY LANGUAGE