HomeMy Public PortalAbout9021 PENTLAND ST_Sewer__ - u
WORKERS'COMPENSATION DECLARATION
winhereby affirm that I have a certificate of consent to self ,
sure or a cerehcate of Workers Compensation Insurance, or ZeAUM r
fled copy thereof 3800 Labe ) CE BDB(RNB'BiI
Policy APPLICATION FOR PERMIT
Policy No Company ®s
❑ Ce�oified copy is hereby furnished SEWER - SEWAGE DISPOSAL t
❑ Certified copy is filed with the county budding inspection `� / OUNV Fig, TTY I�LOS AN ELES BUILDING AND SAFETY 3 t
department _
Date Appltcont APPLICANT TO FILL INV�N�E
CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS BUILDING
COMPENSATION INSURANCE ADOREss DEPTH
(This section need not be completed if the work involved by the �21k it �.... I LIPPE Rpermit is for one hundred dollars (5100)or less ) LotALITY i9e-
C3aI certify that in the performance of the work for which this t CROS SST CTK>H IE- FROMB Pl MLperms rs issued 1 shall not employ any person in any manner PC NDso as to b <o a subject to the Workers Compensation Laws OWNER Q 7/ JOB NO
Awn
` Date a Applicant V`�Vi�l ADDRESS R
J ( TRUNK PERMIT NO
ROAD PERMIT NO
NOTICE O PPLICANT If after making this Certificate Of' EL NO O PFfIDAVIi WAIVER EASEMENT RKORD INSTR Pq DATE
Exemption you should become subject to the Workers UGAt
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 s BLOCK TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION FRO OF BLOCS PERMIT No
!
I hereby affirm that I am licensed under provisions
OF LOT NOW ON LOT 7ions of Chapter J
9 (commencing with Section 7000) of Division 3 of the Busi USRD NGS C �Tv USC, CHARGES
ness and Professions Code and my license Is mlfull force and . _
effect ' - CONTRACTOR - CONNECTION CHARGE FEE Y
License Number LIC Class , ACORIESS REIMBURSEMENT FEE 1116
O
Contractor Date DISTRICT NO GROUP MAP PROCESSED BY V
CITY TEt NO ��/ /� BK ,,,, ,� /f (J Z
❑ am exempt under Sec of the L A Co LICENSE NO J DOqu J �U( !(\_ JJ 1`�(( '\J O
Plumbing Code and/or Sec ofthe NO DESCRIPTION OF WORK FEE FINAJ. V
HOUSE SEWER CONNECTING TO DATE VALIDATION W
B 8 P Code for the following reason PUBLIC SEWER (l-t,-�, N
SEPTIC TANK SEEPAGE PIT OR
MTS AND/OR DRAINFIELD FINAL
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DI&POSAI SYsTFM
Signature OJNNECT ADDITIONAL BLDG OR
OWNER BUILDER DECLARATION WORK TO HOUSE SEWER
I hereby affirm that I am exempt from'the Contractor's License CyArFL5�PAaELEATa5ovwiMANHOLE iO
Law for the following reason (Secton 7031 5 Buisness and Pro- ALTER REPAIR OR AaAND(DN H01tSE '
femoris Code) SEWER OR DISPOSAL SYSTEM - 1
ACCT..
❑ I,as owner of the property or my employees with wages as 3307 '27-50
their sole compensaban will do the work and the structure JJV
Is not Intended Or offered for sole (Section 7044 Business 1 ITEM
and Professions Code) OWNERS Permit E U - +-y
❑ 1 as owner of the property am exclusively contracting with sr AUTHORIZATION TOTAL FEE TOTAL 27 . 50
licensed contractors to construct the project (Section 7044 I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO - !'LJ!• `/I/ 27s W
' Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWEwNG TO THE PUBLIC SEWER MCK
CONSTRUCTION LENDING AGENCY �T 7� , C .00
P.X
I hereby affirm that there is a construction lending agency SIGNED THIS 6 D OF Uf/ 19-0
for the performance of the work for which this permit is OWNER OR IU\-xl)w�-111 •6V.n/_R-\
Issued (Sec 3097 Civ C ) M OWNERS AGENT R
Lender s Name AocRrss 0000-0001 8/18781
Lender s Address 5152 _ 1- Ali sOi%421
I certify that I have read this application and state that the
above information iF correct I agree to comply with all County -
ordinances and State lows regulating Plumbing and Sewers
and hereby authorize representatives of this County to enter
upon t abov mentioned property for inspection purposes
XSignature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE