HomeMy Public PortalAbout9238 OLIVE ST_Sewer__ WORKWbS'COMPENSATION DECLARA?ON
f ,l h*rehy offism_ _I Nive w certificate of consent to self �1
insurlor a certificate, &Worki rs'Compensation Insurance, or 76A642D L`
cot.,,red copy thereof (Sec. 3800, Lab C.)
_ CCEE3808(REV.8/81) APPLICATION FOR PERMIT
Policy No-Lo-e Compony e-`a-j/1
❑;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 //1 '6% Applicant J gel Oc FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDRESS j STATION DEPTH
This section need not be completed if the work involved b the UPPER
( P Y - MANHOLE REFERENCE
permit is for one hundred dollars ($100)or less.) LOCALITY LOWER
I certify ingi in the performance Of the Work for WI11Ch this NEAREST +' TYPE OF CONNECTION LENGTH FROM
P CROSS ST. y� T--I[,.2.�-� Y. CURB 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. OWNER / P.C.NO.
,f ��/I/�;/ CO.IMP.NO. 108 NO,
MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
DDRESS
Date,f//� Applicant !%ls'fr fir l �'du°'L ArC'f r ISG e /�ta€'ss�� ✓'ek"
NOTICE TO APPLICANT: If, after makingthis Certificate Of ! AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
CITY f;r�-r ,f�' �/ TEL.No.Fr i%�) a7 ` --3C ,3'C
Exemption, you should become 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
LICENSED CONTRACTORS DECLARATION NO of PERMIT No
LOT
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 a
is 1-A4/v!
effect. _ CONTRACTOR /!I"'+-t .:t CONNECTION CHARGE FEE
J �
License Number c7�' /a�G- Lic.Class ADDRESS }. /C/
REIMBURSEMENT FEE O
Contractor Date € �j� ^4n (, DISTRICT NO. GROUP' MAP PROCESSED By u
CITY & I` TEL.NO,/r� ..f ` l/' 1
SK PG Z
❑ 1 am exempt under Sec, of the L.A.Co. LIC NSE NO aA` uc.ss O
3�a �C .S
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL, / W
HOUSE SEWER CONNECTING TO J" DATE'_ VALIDATION y
,
B. & P. Code for the following reason PUBLIC SEWER
3 SEPTIC TANK,SEEPAGE PIT ORZ
/
Date,/x- PITS AND/OR DRAINFIELD FIN 6/1
q
HOUSE SEWER CONNECTING TO 5 �1 I t
PRIVATE DISPOSAL SYSTEM 1/`�-
Signature y .+'s f'R +ice` CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION
WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAWFIEID rr--
` `1
I hereby affirm that I am exempt from the Contractor's license ExrN,cessPooL,DRYwELL,MANHOLE �) ,.;� r A
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE r nn
fessions Code): SEWER OR DISPOSAL SYSTEM . le
❑ 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 $ i:_ 7,E c
❑ I, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE ) Lei 7
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY ►
I hereby affirm that there is a construction lending agency SIGNED THIS +FF� DAY OF 70 19_i'
for the performance of the work for which this permit is DINNER oR ------
issued (Sec. 3097, CIv..C.). O`NNERSAGENT�q �� � ^ '
i�`f
Lender's Name
Lender's Address
I certify that I have read this application and state that the
above information is correct. 1 agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upon*he above-menti property for inspection purposes.
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE