HomeMy Public PortalAbout5615 PERSIMMON AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self 920002 DPW 3/87
insure, or a certificate of Workers'Compensation Insurance, or 76A642D
a certified copy thereof (Sec. 3800, Lab C.) CE 808 APPLICATION FOR PERMIT
Policy No. Company ®s
❑ 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 _Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING }
COMPENSATION INSURANCE ADDRESS JF 'f i`+'!/k�' '` ' ftp STATION DEPTH
(This section need not be completed if the work involved by the MANHOLE REFERENCE UPP
permit is for one hundred dollars ($100)or less.) ocAury ">� t ! `` LOWER
NEAREST ' �' TYPE OF CONNECTION LENGT FROM
I certify that in the performance of the work for which this CROSS ST �, i !e`" mat t ii Y. CURB P MA TO P.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, 111-DINGS
NER Co.IMP.No. JOB No:
IL J--- TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant DRESS r? �j !1 �., )�* �£,,...
1 - AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
NOTICE TO APPLICANT: If, after making this Certificate of CITY !`y No. �k .-• �j
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith CRIPTION LOT NO.
comply with such provisions or this permit shall be deemed HWY.ORST.WIDENING
PY P P $- rl a -
revoked. CK �, .� Wil' TRACT% STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION + rNO.OF BLDGS PERMIT NO.
E OF LOT _ VOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter of
9 (commencing with Section 7000) of Division 3 of the Busi- + "t,Lir- CHARGES
ness and Professions Code, and my license is in full force and
effect. CONTRACTOR ' •'w,a ;;.;r l` CONNECTION CHARGE FEE
License Number LIC.Class ADDRESS REIMBURSEMENT FEE
O
Contractor DateCITY TEL.NO. DISTRICT NO. GROUP MAP PROCESSED BY Cj
BK PG �-
❑ I am exempt under Sec. of the L.A.Co. S ATE No. CLASS }/''''' Z
CENPlumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL
HOUSE SEWER CONNECTING TO DATEVALIDATION W
B. & P. Code for the following reason PUBLIC SEWER V)
SEPTIC TANK,SEEPAGE PIT OR FINAL ` `, ,._... Z
PITS AND/OR pRAINFIELD
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR ►
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
I hereby affirm that 1 am exempt from the Contractor's License OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL,DRYWELL,MANHOLE
Low for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE }.
feS ions Code): SEWER OR DISPOSAL SYSTEM -
LJ 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
and Professions Code). OWNERS Permit $
1,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE11c`
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 �7 �`# 9 ,
I hereby affirm that there is a construction lending agency SIGNED THIS ja!..• DAY OF�w f 4-'O 19
for the performance of the work for which this permit is OWNER50AGENr "1.:2' Y J 2i
issued (Sec. 3097, Civ. C.).
ADDRESS_-,--__ .�_, r'Y' a��nc's,
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 grope r i spection purposes.
y F
Signature of Perm Ittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE