HomeMy Public PortalAbout5721-5723 RENO AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or 76A642D
Policy y t' Company"
38 La
Lab .) t �,� C0E5808(REV.II!II,, APPLICATION FOR PERMIT
❑
Certified(copy is hereb . rnis ed. SEWER - SEWAGE DISPOSAL
[�Lertified copy is filed o'unty ildi spection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Date 11-)N-_ Applica t 1 �°1 . 17 FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF E 110 FROM WO ERS' BUILDING ? — a STATION DEPTH
COM PENS T ON INSURANCE ADDRESS +' e,n t r
00
(This section need not be completed if the work involved by the LOCA urY MANHOLE REFERENCE 3� +� 1 .`5 UPPE
permit is for one hundred dollars ($100)or less.) ' L ER
that In the performance of the work far Which this NEAREST G TYPE OF CONNECTION LENGTH FROM
I certify P CROSS ST, A Y. CURB /P L) M.I.TO P L.
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. ry ` P.C.NO.
OWNER �„: 41 1 _. `��% CO.IMP.NO. JOB NO.
� ^ MAIL tn� ( TRUNK PERMIT NO. ROAD PERMIT NO.
Date i 10'
��r� Applicant
- ADDRESS Y `,,�
NOTICE TO APPLICANT: If, after making this Certificate of CITY NO. AFFIDAVIT WAIVER EASEMENT RECORD-INSTR.NO. DATE
_� TEL.
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- BUILDINGS CHARGES
ness and Professions Code, and my license is in full force and
effect. CONTRACTOR n
CONNECTION CHARGE FEE >_
LL.
License Number Lic.C1gsS_ ADDRESS q ;REIMBURSEMENT FEE
Contractor Date "� Ft DISTRICT NO. GROUP MAP PROCESSED BY U
CITY OAen �. TEL.NO. 't [ K PG z
El am exempt under Sec, of the L.A.Co. ST vsE No. I qa sS cLI LAss 0
NO. D SCRIPTION OF WORK FEE
Plumbing Code and/or Sec. of the FINAL _ , 'IQ
HOUSE SEWER CONNECTING TO DATE y,
OU
B. & P. Code for the following reason SUBUc sEi
SEPTIC TANK,
SEEPAGE PIT OR
Date PITS AND/OR DRAINFIELD
PRIVATE DISPOSAL O-�SY SYSTEM
TO BY �, C/.�'C ,� �" a �.•
Signature CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER ► d (< (�
OVERFLOW SEEPAGE PIT,DRAINFIELD
I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE o Q ® r
Law for the following reason (Secton 7031.5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM _
❑ 1,as owner of the property,or my employees with wages as t '
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business
and Professions Code). O ERS r t $
❑ 1,as owner Of the property,am exclusively contracting with AUTH RI TIO TOTA FEE ::IAT 5ZI
licensed contractors to construct the project (Section 7044, 1 HAVE AT IS DATE A UNTRACT WIT THE AMED CONTRACTOR TO
Business and Professions Code). HAVE
TH BOVE DE CRIBED EXISTIN DWELLING TOT PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY osssr���''' r "
1 hereby affirm that there is a construction lending agency SIGNED THIS DOG,` 9
for the performance of the work for which this permit is OWNER OR ,
p OWNERS AGE
issued (Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
Lender's Address C
I certi t t 1 have read this application and state that the
a6ov infor� anon is correct. I agree to comply with all County 9
ordi antes nd State,to regulati Plumbing and Sewers,
an hereb autho&rentat" es?of this County to enter
up n the bo -mrop ty f r inspection purposes.
r
Signature of PeFmittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE