HomeMy Public PortalAbout9924 OLIVE ST_Sewer__ WORKERS'COMPENSATION DECLARATION
elZy affirm that I have a certificate of consent to self
re, or a certificate of Workers'Compensation Insurance, or 76A642D �r
tified copy thereof(Sec. 3800, Lab C.) 92-0002 DPW 6/88 APPLICATION FOR PERMIT
1 No. Compalny
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 _._.ApplicantFOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDINGa �^q a,a STATION DEPTH
COMPENSATION INSURANCE ADDRESS t t
(This section need not be completed if the work involved by the LOCALITY MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOWER
NEAREST
I certify that in the performance of the work for which this CROSS ST. TYPE OF CONNECTION LENGTH FROM
permit is issued, I shall not employ any person in any manner Y. CURB P.L. M L TO P.L.
so as to become subject to the Workers' Compensation Laws. Qr� �- P.C.NO.
I p OWNER sL 2 CO.IMP.NO, JOB NO.
MAIL
Date Applicant ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO._T
° °
NOTICE TO APPLICANT: If, after makingthis Certificate of `[[ t`i AFFIDAVIT WAIVER EASEMENT RECORD INSTR.NO DATE
CITY TEL NO. k 1`'" 4
Exemption, you should become subject to the Workers' LEGAL i
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 f �7 1 STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO of LOT dF PERMIT NO.
I hereby affirm that I am licensed under provisions of Chapter USE OF
Lor �; Now ON Lot
9 (commencing with Section 7000) of Division 3 of the Busi- USE
CHARGES
ness and Professions Code, and my license is in full force and
effect. CONTRACTOW- - CONNECTION CHARGE FEE
License Number LIC.CIgSS ADDRESS REIMBURSEMENT FEE
Contractor Date DISTRICT NO. GROUP MAP PROCESSED BY Z
CITY TEL.NO. BK PG 0
❑ !am exempt under Sec. _of the L.A,Co. LICENSE NO CLASS fj
NO. DESCRIPTION OF WORK FEE
Plumbing Code and/or Sec. of the FINAL UJI
HOUSE SEWER CONNECTING TO ,F" t DATE VALIDATION Z!7
PUBLIC SEWER ,;..t- J' .�" 51
..Q.
B. 8 P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR FINALdq
6.
PITS AND/OR DRAINFIELD �^
-Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR ,
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD
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
e5 tons Code): SEWER OR DISPOSAL SYSTEM
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 I Permit $ � Y SFr
❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION I TOTAL FEE '111.5
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 DAY OF 19_
for the performance of the work for which this permit is OWNER OR
issued (Sec. 3097, Civ. C.). OWNERS AGENTADDRESS
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 (epresentatives of this County to enter
upop the aboke-menti ed property for in;pectio pur oses.
." Pv �: I
Signature of Permitted I' Date ; SEE REVERSE FOR EXPLANATORY LANGUAGE