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HomeMy Public PortalAbout6018 RENO AVE_Sewer__ 3 WORKERS'COMPENSATION DECLARATION t 1 I-er&y arfirm that I have a certificate of consent to self ipvtire, ora certificate of Workers'Compensation Insurance, of 76A642D a certified copy thereof (Sec. 3800, Lab C.) CE BOB(REV.8/81; APPLICATION FOR PERMIT Policy No. Company ©s ❑(Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL LJ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Date Applicant__ FOR PPL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING / COMPENSATION INSURANCE ADDRESS STATION DEPTH (This section need not be completed if the work involved by thePPER NHOLE REFERENCE permit is for one hundred dollars ($100)or less.) LOCALITY I certify that In the performance Of the work for which this CROSSSST YTYPE OF CONNE N LENGTH FROM . CURB permit is issued, 1 shall not employ any person in any manna+ P. MA.TO P.L. so as to become subject to the Workers'Compensation Laws. .B NO, OWNER COCC.IMP.NO. JOB NO. MAIL TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADE Rf.55 NOTICE TO APPLICANT: If, after making this Certificate Of ITY NO. AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE 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 SIZE OF LOT NOW ON LOT NO OF LOT P.RMIT No. + I hereby affirm that I am licensed under provisions of Chapter USE F 9 (commencing with Section 7000) of Division 3 of the Busi- BuitOF CHARGES ness and Professions Code, and my license is in full force and effect. CONT RACT CONNECTION CHARGE FEE License m4Sec Lic.Class �� ADDRESS REIMBURSEMENT FEE CDate CITY O. Z DISTRICT NO. GROUP MAP PROCEd ED BY BK PG ❑ I am exempt of the L.A.Co. STATE QJ uC . (jPLICENSE NO. T CLAS ' NO. DESCRIPTION OF WORK FEE Plumbing Code and/or Sec. of the FINAL HOUSE SEWER CONNECTING TO GATE //"''C/, VALID AV ION EL PUBLIC SEWER ,,..• �< // B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR FINAL z PITS AND/OR DRAINFIELD �p Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature - CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD 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 _ ;9 J 1 ,t r A ❑ I,as owner of the property,or my employees with wages ci , ® ( their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNERS Permit S � j f ( • ` 7 ❑ 1, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE q-7 >' + �' Z licensed contractors to construct the project (Section 7044, H�E _,� TR A SHE HEREIN NAM CONTRACTOR TO Business and Professions Code). CO (STING D�DEUI T THE uBLIC SEwE ( " CONSTRUCTION LENDING AGENCY /JJ� I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF for the performance of the work for which this permit is OWNER OR issued (Sec. 3097, Civ. C.). OWNERS A Fr ADDRES' Lender's Name Lender's Address I certify that I ve read this application and state that the above inform n is correct. I agree to comply with ounly ordinances d State laws regulating PI bing d Sewers, and her authorize representati o is unty to entfr upor ova-mentioned p for sp tion purpas s. i Signature of Permittee Dat �w i SEE REVERSE FOR EXPLANATORY LANGUAGE