HomeMy Public PortalAbout5626 PERSIMMON AVE_Sewer__ WORKERS'CONIPENSATION DECLARATION CE 808 2D 76A64
* 4, (2 80) APPLICATION FOR PERMIT
I lwet`;,� 40firrit that I have a certificate of consent to sell SEWER-SE'VV'_4q
DISPOSAL
.) COUNTY OF LOS ANGELES
insure, or a certificate of Workers'Compensation Insurance,or Cc
a certified copy thereof(Sec.3800,Lab. BUILDING AND SAFETY
Policy No--Company e-1
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN CONNECTION DATA
BUILDING STATION DEPTH
-e county building inspection ADDRESS
E] Certified copy is filed with th UPPER
department. REFERENCE
LOCALITY MANHOLE: E: 0 WER
:z
Date— Applicant-- NEAREST TYPE OF CONNECTION LENGTH FROM
-ICATE 01' EXEMPTION FROM WORKERS' P.L.
CROSS S�. Y. CURB P.L.. . M.L., TO I
CERTIF
COMPENSATION INSURANCE �? P.C, NO,
OWNER CO. IMP. NO. I.. NO.
MAIL
(This section need not be completed if the work involved ADDRESS MfgTRUNK PERMIT NO. ROAD PERMIT NO.
by the Permit is for one hundred dollus ($100) or less.) .WAIVER JEASEMENTIRE.CoRD. INS'YR.NO.
C f y y TEL. NO.
1 certify that ill the performance of the work for which this LEGAL 1DATE
permit is issued, I shall not employ any person In any manner DESCRIPTION LOT NO, HWY. OR ST. WIDENING
so as to become subject to the Workers' Compensation Laws.
BLOCK TRACT STATE ENCROACHMENT
Date-- Applicant NO. OF E3 LDGS- PERMIT NO,
NCTIC1: TO APPLICANT: If, after making this Certificate of SIZE OF LOT NOW ON LOT
0-
Exempiion, You should become subject to the Workers' USE OF U)
Compensation provisions of the. Labor Code, you must forth- BUILDINGS CHARGES
with comply with such prAr)visions or this permit shall be CONTRACTORCONNECTION CHARGE FEE:
deemed revoked. A""
LICECTE
NSED ONRACTORS DCLD
ARATION ADRESS REIMBURSEMENT FEE
I hereby affirm that I am licensed under provisions of ChapterWST.ICT NO. CROUP MAP
9 (commencing with Section 7000)of Division 3 (J the Busi- CITY TE CROUPSK PG PRO ss EQ -Y
nesA; and Profession,; Code, and my license is in full force and STATE LIC.
LICENSE NO. CLASS s/
effect.
NOT--o-ESCFi 4 PT ION OF WORK FEE -1
FINAY
.O.S. E1,W.. CONNECTING 1. VALIDATION
License Number-- Lie.Class----- P,JVLIC SEWERDATE
SEPTIC TA.",srFP.c.E PIT DR
Contractor----- Date PITS.A.N D J.R DR.I.ESELD
HOUSE; W
FIN
'ES.NE
—RIATE01510
$YSTE"',
ank exempt from the licensing requirements as I am a
WORK TO ."'S.
0 NECT ADDITIONAL BI-DO.OR
licensed architect or a registered professional engineer C. SEWER x
acting in nay professional capacity (Section 1051, Bus- —E— OW SE.CP..F PIT,—INIIEL.
inv.ss and Profcssions Code). LX7N.,CESSPOOL,DRYWFLL,MANHOLE
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
Lie,or Reg. Date
HOME OWNER-BUILDER DECLARATION
I h affirm that I ani exempt from the Contractor's OWNER'S Permit
lt� ly r7l, the following reason (Section 7031.5, Busi- TOTAL FEE
Lice La", if AUTHORIZATION
I and Professions Code): I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN 4ZA... CON-
IRACTOR TO CONNCCr THE ABOVE OESCFt ED x45TIN0.QW ILLING
Y, as owner of the property, will do the work acid the TO THE PUBLIC SEWER.
structure is not intended or offered for sale (Section SIGNED THIS DAY OF is
7044, Business and Professions Code).
OWNER Or
OWNERS AGENT
CON-STPUCTION 1.1,.'N)--)[N(; A.GENCY ADDRESS__
I hereby affirm that there is a construction. lending agency
for the perforinatice of the work for which this permit is
issued (So c 3097,Civ.C,).
Lender's Name—,
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 Se,.vers,
and hereby authorize representatives of this County to enter
above-men ionl';d pro,r•rty Ryr inspection purposes.
eSFE REVERSE FOR EXPLANATORY LANGUAGE
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