HomeMy Public PortalAbout9556 OLIVE ST_Sewer__ WORKERS'COMPENSATION DECLARATION ,ti '
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or 76A642D
a certified copy thereof (Sec. 3800, Lab C. CE 808(REV.(3/811 APPLICATION FOR PERMIT
Policy No.-Company 7s
[� 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. F y
Date Applicants FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION'
COMPENSATION INSURANCE AbDRess ' ;
y*• ._-_,. _�..7
(This section need not be completed if the work involved by the z MANHOLE REFERENCE UPPER -
permit is for one hundred dollars ($100)or less.) LOCALITY irtr' t ` a LOWER
NEARESTj� TYPE OF CONNEC ON LENGTH FROM
I certify that in the performance of the work for which this cRoSs sr. s 7 Y. CURB ¢ M L-TO P.L.
permit is issued, I shall not employ any person in any manner 11 )}
so as to become subject to the Workers'Compensation Laws. OWNER _ V CO.IMP.NO. P.C.NO
JOB NO.
K•PERMIT NO. =� ROAD PERMIT NO. yf J�;:"�-(�
Date Applicant AcoREss ,4 !.,� 1 ,r iii
14 AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. '' TE ! O
NOTICE TO APPLICANT: If, after making this Certificate of CITY "rl L TEL.NO. U
Exemption, you should become subject to the Workers' LEGAL W
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY OR ST.WIDENING ft-
comply
comply with such provisions or this permit shall be deemed 63)
-evoked. BLOCK TRACT STATE ENCROACHMENT Z
NO.OF BLDGS. PERMIT NO.
LICENSED CONTRACTORS DECLARATION 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 r J �- CHARGES
ness and Professions Code, and my license is in full force and
effect. CONTRACTOR 0 (; . '44-1 "5 CONNECTION CHARGE FEE
License Number Lic.Class ADDRESS ! ' � REIMBURSEMENT FEE
`T,Contrador ty DISTRICT NO, GROUP MAP PROCESSED BY
+ CITY
Date j
.f TEL.NO. BK PG.
a
�r3� rr-�
❑ I am exempt under Sec. of the L.A.Co. i CENSE NO. st {� ciAss
NO. DESCRIPTIO OF WORK FEE -
Plumbing Code and/or Sec. of rhe FINAL , VALIDATION
HOUSE SEWER CONNECTING TO - DATE
B. 8 P. Code for the following reason PUBLIC SEWER r
SEPTIC TANK,SEEPAGE PIT OR FINAL
PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR '
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWERf �7
OVERFLOW SEEPAGE PIT,DRAINFIELD l.2' r '{
I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYW'Eil,MANHOLE us a.?
Low for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM
1,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 d.
and Professions Code), OWNERS Permit $ t .,
lJ 1,as owner of the property,am exclusively contracting with AUTHORIZATION I TOTAL FEE P
licensed contractors to construct the project (Section 7044, i 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 SIGNED THIS DAY OF �"- 19
I hereby affirm that there is a construction lending agency �y
for the performance of the work for which this permit is i OWNER 7 '' `
issued (Sec. 3097, Civ. C.). OWNERS AGENT
w�
ADDRESS
__ 151171
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 hereby authorize representatives of this County to enter
upon the above-mentioned roperty for inspection urpo s.
^
.,
Signature ofPermittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE