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HomeMy Public PortalAbout9461 OLIVE ST_Sewer__ WORKERS'COMPENSATION DECLARATION affirm that I have a certificate of consent to self o'certificate of Workers'Compensation Insurance, or - 76A642D ified copy thereof (Sec. 3800, Lab C.) CE BOB(REV.8/8) APPLICATION FOR PER IT No. Cortapany ©s d copy is hereby furnished. SEWER - SEWAGE DISPOS ❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDIN AND SAFETY department. Date._ _Applicant FOR APPLICANT TO FILL IN C NNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING y- STATION } DEPTH COMPENSATION INSURANCE ADDRESS t (This section need not be completed if the work involved by the LOCALITY 7 — MANHOLE REFERENCE ft UPPER permit is for one hundred dollars ($100)or less.) V I certifythat in the performance the NEAREST TYPE OF CONN TI LENGTH FROM P ormance oe work CROSS ST. (;1 V r'' Y. CURB P.I, M,I.TO P.L. permit is issued, I shall not employ any person ifor which this n any manner so as to become subject to the Workers' p s ion ws. (r - I C'[ CO.IMP.NO. JOB NO. OWNER ryF MAIL /{ Date"! L�Applicant ADDRESS C '161 ( / (/ �'t c TRUNK PERMIT NO. ROAD PERMIT NO �j ✓ AFFIDAVIT WAIVER SEMENT RECORD.INSTR.NO. DATE NOTICE TO APPLICANT If, aft makin this Certificate ofy�{- s 3 CITY 'd TEL.NO. - Exemption, you should bec 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 . LICENSED CONTRACTORS DECLARATION NO,OF BLDGSPERMIT 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 y^ effect. CONTRACTOR CONNECTION CHARGE FEL � CL License Number Lic.Class ADDRESS ryvi� REIMBURSEMENT FEE O Contractor Date DISTRICT NO. GROUP MAPPROCESSED BY V CITY TEL NO. �/ 6K PG Z_ ❑ I am exempt under Sec._ of the L.A.Co. STATE CENSE NO. CLAS sF lP DESCRIPTION OF WORK Plumbing Code and/or Sac. of the NO. FINAL VALIDATION HOUSE SEWER CONNECTING TO DATE H PUBLIC SEWER — ---, — B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR FINAL Z PITS AND/OR DRAINHELD Date — HOUSE SEWER CONNECTING TO BY [ PRIVATE DISPOSAL SYSTEM Signature, CONNECT ADDITIONAL BLDG.OR ' ► OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER , I hereby affirm that I am exempt from the Contractor's License OVERFLOW SEEPAGE PITDRAINFIELDEXTN,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Secton 7031.5, BUisness and Pro- ALTER,REPAIR OR ABANDON HOUSE 01 feS510 Cade)' �.(?.)'!•s SEWER OR DISPOSAL SYSTEM a - - # 1,as owner of the property,or my employees with wages as 330 7 -, their sole compensation, will do the work and the structure it+5tli =•' ' is not intended or offered for sale (Section 7044, Business and Professions Code), OWNERS Permit $ 1 I EN ❑ 1,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE �` S TOTAL 32•■"�O licensed contractors to construct the project (Section 7044, t HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTWACTOR TO Business and Profession$Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER S' T''HECIl 32•% CONSTRUCTION LENDING AGENCYt:(- 19�I; ► ANGG .If o I hereby affirm that there is a construction lending agency SIGNEDTHISDAYOF for the performance of the work for which this permit is owNER OR ^7 issued (Sec. 3097, CIV. C.), OWNERS AGENT / C. • GVt "/ is rt+j EFF Lender's Name ADDRESSU iw .� v.••hlti 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 hereby authorize representatives of this County to enter uponfhe a ve en d property for inspection purposes. Q Si ure Permittee Date J SEE REVERSE FOR EXPLANATORY LANGUAGE