Loading...
HomeMy Public PortalAbout9622 OLIVE ST_Sewer__ t, th'GPKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance, or 76A642D aycert4ied copy thereof (Sec. 3800, Lob C �,-�. �/ 92-0002 DPW 6/88 11 Policy Nd�Compony—=t 1 'UnLZ� APPLICATION FOR PERMIT Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY deport er 1. Date 1® � Applicants`' �X116 /VNL S FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION DEPTH COMPENSATION INSURANCE ADDaess This section need not be completed if the work involved b the UPPER ( p Y � � 7" • MANHOLE REFERENCE LOCALITY LOWER permit is for one hundred dollars ($LOO)Or less.) NEAREST �+ TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS 5T 7? r ✓ Y. cuRO P.L, M.L TOP,L: permit is issued, I shall not employ any person in any manner P.C.No so as to become subject to the Workers'Compensation Laws. OWNER �J CO.IMP.NO. JOB NO. MAIL �/ Date—Applicant ADDRESS y TRUNK PERMIT NO. ROAD PERMIT NO. NOTICE TO APPLICANT: If, after makingthis Certificate Of -y AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE CtTYre- C y Y TEL.NO 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 V' �6 STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATIONZ� , NOW F B LOTS PERMIT NO. SIZE OF 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 "Je7 CHARGES d ness and Professions Code, and my license is in full force and effect. CONTRACTOR � M i CONNECTION CHARGE FEE CL Licenssx�e Numbte'rS� Lic.Classy p//} ADDRESS AI S REIMBURSEMENT FEE fe'r,rfsGlr.1/ViS� Date I"'© __.L.U_.__.__ CITY. G� DISTRICT NO. GROUP MAP PROCESSEURY z Cont actor r ____ TEL.NO. yD^,3 BK PG b -__Zl ''�'' STATE LIC. ❑ I am exempt under Sec. _of the L.A.Co. LICENSE NO. CLASS r. Plumbing Code and/or See. of the No. DESCRIPTION OF WORK FEE FINAL HOUSE SEWER CONNECTING TO DATE VALIDATION W B. & P. Code for the following reason PUBLIC SEWERSEPTIC TANK,SEEPAGE PIT OR ✓�� Z PITS AND/OR DRAINFlELD FINAL - 42 T0 HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG,OR OWNE - ILDER DELA—RATION WORK TO HOUSE SEWER Vii' ► s OVERFLOW SEEPAGE PIT,DRAINFlELD 4 I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Secton 7031.5, BuiSness and Pro- ALTER,REPAIR OR ABANDON HOUSE fession5 Code); SEWER OR DISPOSAL SYSTEM - rp^ •iL , ❑ 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 $ IL ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION 1 TOTAL FEE ' licensed COnfractOrS to construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO q it i Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. ` CONSTRUCTION LENDING AGENCYQry I hereby affirm that there is a construction lending agency SIGNED THIS DA F 19Lk for the performance of the work for which this permit is OWNERSOAGE issued (Sec. 3097, Civ, C.). cc J ADDRESS Lender's Name Lender's Address x I certify that I hove 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-mention d property for inspection purposes. zoo_ y`/1 Slgn r@ of Permittee Date J SEE REVERSE FOR EXPLANATORY LANGUAGE