HomeMy Public PortalAbout9437 PENTLAND ST_Sewer__ • WORKERS COMPENSATION DECLARATION �1
I hereby affirm that I have a certificate of consent to self 'll
Insure or a certificate of Workers Compensation Insurance or >•anea•fp LS
acertifiedt r f (Sac C CEeaB(REV B,B,I APPLICATION FOR PERMIT
Policy No companyny— .9-d� ®° SEWER - SEWAGE DISPOSAL
�❑ Certified copy is hereby furnished � _
L9�Canlfled copy Is filed with the county building Inspection _ COUNTY OF LOS ANGELES BUILDING AND SAFETY
department
Date Applicant 's <l �wtSYS FOR APPLICANT TO FILL IN' CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS BUILDING /L
COMPENSATION INSURANCE ADDRESS STATION DEPTH
(This section need not be completed If the work Involved by the �,� C' M,wHOU REFERENCE UPPER
permit Is for one hundred dollars ($100)or less ) LouuTv tO VER
I Certify that in the performance of the work for which thisNFAREBT TYPE OF CONNECTION UNGTH FROM
CROSS Si L IAI� Y CURB PL ML TOP L
permit is issued I shall not employ'any person In any manner
so as to become subject to the Workers Compensation Laws i F G
OWNE0. � fL A- StN� CO IMP NO LOB NO NO
MALI
Date Applicant ADDRESS (/� TRUNK PERMIT NO ROAD PERMIT NO
/
NOTICE TO APPLICANT If after making this Certificate of CITY /( �J 7 TEE NO AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
Exemption you should become subject to the Workers
LEGAL
co14
mply
On provisions Of the Labor code you must forthwith ed DESCRIPTION LOT NO HWY OR ST WIDENING
. comply with such provisions or this perms shall be deemed ,T
revoked BLOCK O V TRACT STATE ENCROACHM
LICENSED CONTRACTORS DECLARATION r+O OF BLDC5 HERMIT FID
SIZE OF Loi NON ON LOT
hereby affirm that Se liceion led under provisions f t Chapter USE OF /
9 (commencing es with Section d my of Division 3 of the BUST BUILDINGS ✓ ze plgRC{y
ness and Professions Code and my license is in full force and
effect -/ / CONNECTION CHARGE FEE
[/ CONTRACTOR f// �(. � .y,s }
License Number / Lc Class 0.
//..,, p 1EE��JJ ADDRESS �' /A ,��� REIMBURSEMEM FEE O
Contractor LM.D iJ DptO � CITY s h/('L— TEL NO ZZ� WSTRKT NOJGRCAJPMAP PROCESSED BY V
5 0 BK r O
STALE UC
❑ I am exempt under Sec of the L A Co LI�NSE NG cuss •C`
Plumbing Code and/or Sec of the ho DESCRIPTION OF RK TEE FINAL
HOUSE SEWER CONNECTING TO DATE W
B & P Code for the following reason PUBLIC SEWER Z _ C VALIDATI W
SEPTIC TANK SEEPAGE%i OR 'L
Date PITS AND/OR DRAINHELD FINAL
FO SEWER CONNECTING i0 BY
ATE DISPOSAL SYSTEM
Signature CONNECT ADan1O X BLDG OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER ,
OVERFLOW SEEPAGE PIT DRAINFIELD
hereby affirm that I Om exempt from the Contractors License ERIN CESSEOOL MYWELL MANHOLE
Law for the following reason (Sectors 7031 5 Bwsness and Pro ALTER REPAIR OR ABANDON HOUSE i 0 7 2 8 A
fessions Code) SEWER OR DISEOSAL SYSTEM
❑ .•. . .J 0 I,as owner of the property or my employees with wages as p
their sole compensation will do the work and the structure I •r• 24.50
Is not intended or offered for sole (Section 7044 Business 2)��5 0 6and Professions Code) OWNER'S Permit $ /0
❑ I as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE Q 9 2 2=8 8
licensed Contractors to Construct the project (Section 7044, HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED ONTRACTOR i0
Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER
CONSTRUCTION LENDING AGENCY yBF pool hereby affirm that there Is a construction lending agency SIGNED THIS D 19_
for the performance of the work for which this permit Is OWNER OR
Issued (Sec 3097 Cry C ) OWNERS AGENT r _ //
Lender s Name ADDRESS �G SN/A/� C� E'S /��1a7
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 authorizer KeSentotwes of this County to enter
Upon the av me�rty for Inspection purposes
S71griOE5reofPerMHttee Dote SEE REVERSE FOR EXPLANATORY LANGUAGE