HomeMy Public PortalAbout6031 PRIMROSE AVE_Sewer__ W0RKERS COMPENSATION DECLARATION
.' hereby •offirm that I have a certificate of consent to self `l
Fn,gyire, 'bt a'certificate,.of Workers'Compensation Insurance, or 76Ae42D
thereof See. 3800,tab CEBDB(REV B;B,, APPLICATION FOR PERMIT CQ�rtifieu 40py ( }
P61� y No.______ Company 7s
❑ Certified copy is hereby furnished. SEWER - WAGE DISPOSAL
V Certified copy is filed with the county building inspe tion COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Date '
ApplicantJ ` FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION DEPTH
COMPENSATION INSURANCE ADDRESS - �+
(This section need not be completed if the work involved by theLOCALITY MANHOLE REFERENCE LIPPEF
permit is for one hundred dollars ($100)or less.) iowE?
/ //
1 certify that in the performance of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROMCROSS ST. a7C.t. Y. CURB P L M.L To P.I.
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. P.0 No.
OWNER y� .2 CO.IMP.NO. JOB NO,
MAIL TRUNK PERMIT NO. ROAD PERMIT NO,
Date Applicant ADDRESS
NOTICE TO APPLICANT: If, after makingthis Certificate of AFFIDAVIT WAIVER EASEMENT RECORD !NSTR.NO. DATE
CITY TEL.NO.
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION No.OF BLDGS PERMIT NO. �!
SIZE OF LOT NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter USE OF
9 (commencing with Section 7000) of Division 3 of the Busi- BLmDINGs r CHARGES
ness and Professions Code, and my license is in full force and
effect. CONTRACTOR CONNECTION CHARGE FEE
License Number Lic.Class_ ADDRESS a✓ "�. REIMBURSEMENT FEE
i DISTRICT NO. GROUP MAP PROCESSED BY
Contractor Date_ CITY TEL.NO. (g '+y *�. _ " ..� BK PG /7 J Z
❑ I am exempt under Sec. of the L.A.Co. iCErisE No. - ciASst _fir AL 0
Plumbing Code and/or Sec._^ of the NO. DESCRIPTION OF WORK FEE FINAL W
HOUSE SEWER CONNECTING TO 1 i DATE PUBLIC SEWER VALID ION p, -
L�,. �-- .-
B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR FINAL ' /, ?
ArfS AND/OR DRAINFIELD G
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
3.
Signature CONNECT ADDITIONAL BLDG.OR {/
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD -, 6 7A
I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE
Law for the following reason (Secton 7031.$, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE �}
fe55iar15 Code): SEWER OR DISPOSAL SYSTEM 'v ®!ad
❑ 1,as owner of the property,or my employees with wages as a
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business l
and Professions Code). OWNER'S Permit g � i 3
❑ I,as owner of the property, am exclusively Contracting with AUTHORIZATION TOTAL FEE `f S� �; a,
licensed contractors to construct the project (Section 7044, 's
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
I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_
for the performance of the work for which this permit is OWNER OR
issued (See. 3497, Civ. C.) OWNERS AGENT
ADDRESS
Lender's Name---
Lender's
ame _Lender's Address
I certify that 1 have read this application and state that the
above information is correct. I agree to comply with all C9unty
ordinances and State laws regulating Plumbing and Se ers,
and hereby authorize representatives of this County to; nter
upon the above-mentioned roperty for inspection purpc es.
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE