HomeMy Public PortalAbout5924 RENO AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
I"hereby affipm that I have a cerTtfic6id of consent to self
insure, of a certificate of Workers',Compentation Insurance, or 7GA9420
,a cer-(6ed copy thereof(Sec. 3800, Lab C.) 92_Oc,2DP,v61i56 APPLICATION FOR PERMIT
pPolicy No. _Company, I
L� Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL (I
[] 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' BU TIDING �i
COMPENSATION INSURANCE ADDRESS V' ..d STATION DEPTH
(This section need not be completed if the work involved by the MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LE- T LOWER
I certify that in the performance of the work for which this CROSS 5T. TYPf OF CONNECTION LENGTH FROM
V. CURB P.I. M.L..TO P.l,
permit is issued, I shall not emplo ny perso jn any manner P C.No.
so as to com subject to the Wbers rtAdsation Laws. OWNER CO.IMP.NO. JOB NO
�P�
7 MAIL
;p. ADDRESS �'� TRUNK PERMIT NO. ROAD PERMIT NO,
Date Applicbrtf '' f
NOTICE' TO 'APPLICANT: If, after making
this Certificate of AFFIDAVIT WAIVER EASEMENT RECORD,INSTR.NO DATE
9 CITY TEL.NO ��.
Exemption, you should become subject to the Workers' LEGi
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 SNO.OF BLDGS PERMIT NO.
USE
OF`:CT I S �l�s�'.r NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter Lice GF -i # o"
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 COP-!L,CCTiI; __t�AVGE FEE
License Number _Lic.Class ADDRESS REIMBURSEMENT FEE
Contractor Date CITY TEL NO DISTRICT NO. GROUP MAP PROCEASLD BY
�9 STATE I LIG �,. �T' BK PG rir
I-� I dm exempt under Sec. �.of the L.A.Co. LICENSE NO. CLASSi ' 1`
NO. DESCRIPTION OF WORK FEE
: �I
Plumbing Code and/or Sec. of the FINALG2_
HOUSE SEWER CONNECTING TO DATE <t ""/ •- „°'�• tJ?
'
VALIDAf10N
B. & P. Code for the following reason PUBLIC SEWERSEPTIC TANK,SEEPAGE PIT OR z
PITS AND/OR DRAINFIELD FINAL ..--.-
Date - HOUSE SEWER CONNECTING TO BY -•�'�.% �'.6{” .""
PRIVATE DISPOSAL SYSTEM G
Signature CONNECT ADDITIONAL BLDG.OR ,
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINNELU ILI
I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
feSSiOns Code): SEWER OR DISPOSAL SYSTEM
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 sale (Section 7044, Business
and Professions Code). OWNER'S Permit _$ �_''I :j
❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE t_l
licensed contractors to construct the project (Section 7044, I 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 (Sec. 3047, Civ. C.). OWNERS AGENT •.
ADDRESS
Lender's Name
i.ender's Address
I certify that I have read this application and state that the
above information i"�correct. 1 agree to comply with all County
ordin ces and S t laws regulating Plumbing and Sewers,
an reby h rdz represeyrfatives of this Cou y to enter
6tup a ab e toned operty for spection p oses.
In-Akyj-4 lhxt T-V
i6n ture of Pdrmittee V Date SEE REVERSE FOR EXPLANATORY LANGUAGE
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