HomeMy Public PortalAbout6033 PRIMROSE AVE_Sewer__ 'WbIRKERS"COMPENSATION DECLARATION n
• t hereby •affirrq. thdi .1 -have a. certificate of consent to .self JI�I
Insure,$t a cerifficate,of Workers Compensation Insurance., or P6A644D
a certified copy thereof(Sec. 3800,•tab C.) CE 808(REV.8/:81) a��PCtrsICt�® Is V F® PERMIT Policy No. Company �s
❑ Certified copy is hereby furnished, SEWER ` SEWAG.IE DISPOSAL
Certified copy is filed with the counfy building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
clj
Date Applicant.
/'7•:a' �� EOR.�►PFLIC/4PIT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING' STATION DEPTH
COMPENSATION INSURANCE ADDRESS O
his,section need not be-completed If the work in.volved,b theUPPER
p y LOCALITY � •.MANHOLE REFERENCE _ LL�WER
permit is for One hundred dollars($100)or less.') NEAREST TYPE.OFCONNECTION LENGTH FROM.
I Certify that to the performance of the work for which this ;CROSS ST. Al d— k; CURB P.L. M.L.TO P.L.
pert ift is'issued, 1 shall not employ any person in any manner
so as to become:subject to the Workers"Compensation Laws. OWNER /v CO.iMR,No: JoB No.
NAIL (r• CAR .P�1 +TRUNK.PERMIT NO. ROAD PERMIT NO.
Date Applicant' ADDRESS ' 1I4/
AFFIDAVIT WAIVER EASEMENT RECORD INS7R.NO� 'DATE
NOTICE TO APPLICANT If, after making this Certificate of CI MQ21 aq
Exemption, .you shouldbecorr(e subject to :fhe Workers' LEGAL -
Compensafion,provisions of the Labor:code,you nnust forthwith DESCRIPTION LOT NO. idW1G OR.St.WIDENING
comply with sUch..provisions or this permit shall be deemed'
revoked. BLOCK TRACT :STATE.ENCROACHMENT
LICENSED.CONTRACTORS DECLARATION. NO.OF BLDG$. PERMIT NO.
-SIZEOF•LOT NOW ON I.O.T.I hereby affirm that I am licensed under provisions of Chapter jtS,� �� ,
USE OF 0Q
AJ(commencing with Section 7000) of Division 3 of. the BUST- BUILDINGS OW CHARGES
nest and Professions Code; and my license is i.ri full.:force and
effect. �' CONTRi4CTORMbw CONNECTION CHARGE FEE ,
t
License.Number Lic.Class ADDRESS .REIMBURSEMENT FEE
Contractor DateDISTRICT NO. GROUP MAP massway tel
tR•Y 7El..NO. BK PG Z'
❑ I am exem t under Sec. of the L.A:Ca. STATE LIC.. f//`_ O
p LICENSE NO. CLASS C-42- 0r�� /G
NO.. DESCRIPTION OF WORK FEE
Plumbing Code and/or Sec, of tFie FINALUJI
HOUSE SEWER CONNECTING TO DATE i VALID
f/
B. &.RPUBLIC SEWER P. Code for the following reason D [ rG�. b A
SEPTIC TANK,.SEEPAGE PIT AOR -
. .PITS.AND/OR DRAINFIELD. PIN qe
Date. HOUSE'SEWER:CONNECTING TO. ..o o: o:I,O .0.
PRIVATE DISPOSAL SYSTEM. 11Z _ 1 - -.2750 '
Signature CONNECT ADDITIONAL BLDG.OR 1 0 0 '� Q
OWNER-BUILDER DECLARATION WORK'TO HOUSE.SEWER
,OVERFLOW SEEPAGE PIT,DRAINFI.ELD
I hereby affirm that I din,exempt from the Contractor's License OVERFLOW
OW SEEPAGE
PIT,
D MANHOLE o 0 0 'T �.0
Law for the following reason($scion 7031.5, BuitnesS and Pro- ALTER;REPAIR OR.ABANDON HOUSE'
.fessi.ons Code.): .SEWER OR DISPOSAL SYSTEM �3 2 5-8 7
❑ 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 $
❑ I,as owner'of the property.,am exclusively contracting With AUTHORIZATION 'TOTAL FEEI so
licensed contractors tq construct the project,(Section 7044; I.HAVE AT THIS'DATE A CONTRACT WITH THE HERON'NAMED:CONTRACTOR TO
Business and Professions Code). CONNECT THE ABOVEWSCRIBED EXISTING DWELLING TO THE PUBLIC SEWER
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is'd construcfion lending agency SIGNED THIS DAY OF. 19_
for the performance bf the work for -which this permit is OWNER OR
issued (Sec. 3097;Civ. C.). OWNERS AGENT
ADDRESS
Lender's Name . .. .. . ... ...: ..._.. .,:...
Lender's Address
I certify that I have read this application and state that the
above information is correct. I.ogree to comply with a.11 County
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upon the above-menti.oned property for inspection purposes.
Signature of Permittee Date SEE REVERSE:FOR EXPLANATORY LANGUAGE