HomeMy Public PortalAbout6007 PRIMROSE AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self T,
insure, or a certificate of Workers'Compensation Insurance, or Y6A642D
a certified copy thereof (Sec. 3800, Lab C., CE 808IREV.8,81 APPLICATION FOR PERMIT
Policy No.——Company SEWER - SEWAGE DISPOSAL
Certified copy is hereby furnished.
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' BuuowG �
COMPENSATION INSURANCE ADDRESS STATION i• "57 DEPTH
(This section need not be completed if the work involved by thes MANHOLE REFERENCE
LOCALITY r`'1�1 1`'[ �7-.,1. E r A I LOWER
permit is for one hundred dollars ($100)or less.) --�--- LENGTH FR6M
NEAREST f�`� TYPE OF CON CTION
I certify that in the performance of the work for which this CROSS ST. 1 C fv 1` CURBB, P,I. MA.TO RL. ?"
permit is issued, I shall not employ a persVinny ma r
so as to become subject to the Wo er mi (. P.0 rdo. ps
,��rl �j OWNER ��ccqq CO.IMP.NO. JOB NO.
'�'��"" 9DDRESS V IL ?BUNK PERMIT NO. ROAD PERMIT NO.' V
\,ateApplicar,t
NOTICE TO APPLICANT: If, after makin t'is _ertif' ate of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.No. DATE }
g CITY TKA( �.{L.{�. L.NO.
Exemption, you should become subject the orkers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST WIDENING �T {
comply with such provisions or this permit shall be deemed — ' � / Com" ^•
revoked. BLOCK TRACT STATE ENCROACHMENT _F
LICENSED CONTRACTORS DECLARATION NO.OF BLDGS PERMIT O"
I hereby affirm that I am licensed under provisions of Chapter SIZE OF I.OT NOW ON LOT OF
USE
9 (commencing with Section 7000) of Division 3 of the Susi- BUILDINGS CHARGES
ness and Professions Cade, and my license is in full force and
effect. CONTRACTOR �d� 0 CONNFC11ON CHARGE FEE
3 6
License Number _ .C.Class f ADDRESS5111—f ly
�' REIMBURSEMENT FEE
COnhaftar P to �/ _ C. ♦ //�� �-...� DISTRICT NO. GROUP MAP PR CESSED BY
CITY TEL NO. ♦ �V
PW BK PG y-
STATE �'! LIC.FI
am exe udder Sec. of the L.A.Co. LICENSE No. CLASS
.
Plumbing Code and;'Or Sec. of the NODESCRIPTION OF WORK FEE,HOUSE SEWER CONNECTING TO DATE �
B. 8 P. Code for the f wing re n f oPUBLIC SEWER ALIDATION
SEPTIC TANK,SEEPAGE D OR FINAL
PITS AND/OR DRAINFIELD
-- at HOUSE SEWER CONNECTING TO By
PRIVATE DISPOSAL SYSTEM
S!gnature �C/' CONNECT ADDITIONAL BLDG.OR
O NER-BUILDEyfE LARATI `.YORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD
I hereby affirm that I am exem Cm the ar tractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE
Law for the following reason (Sector 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code,): SEWER OR DISPOSAL SYSTEM
E'
❑ 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 sole (Section 7044, Business
and Professions Code). OWNER'S Permit 5 C
❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE 1'7
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
Business and Professions Cade). 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 F 19
for the performance of the Werk for which this permit is OWNER OR 1
OWN[RS AGENT
issued (Sec. 3097, Civ. C).
ADDRESS Lender's Address
I certify that I have read this application and state that the
rr.above information is correct. I agree to comply with all County
';ordinances and State laws regulating Plumbing and Sewers,
tnd hereby orize repre5yK tatives of t Count to enter
ion the ov -m ticned rope"t or ct" poses.
� Ems- .•�e� � ,.,�� ..l
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE