HomeMy Public PortalAbout5720 RIO HONDO AVE_Sewer__ WORKERS' COMPENSATION DECLARATION
1-h#ray affirm that I have a certificate of consent to self
inspre'cnr a certificate of Workers' pensation Ins ce, or 76A642D
a certile copy fhLreof(Sem. 8 ) ce aoe;REV e al y
Pal,cs�,—`�3,�'C- ; P.S APPLICATION FOR PERMIT
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
Certified copy is filed with�jthounty buil7in inspectio COUNTY OF LOS ANGELES BUILDING AND SAFETY
deparI t,
Dateplica _ .0 ' FOR APPLICANT TO FILL IN CONNECTION DATA
ERTiFICA E OF EXEMPTION FROM WORK BUILDING5 ,/� DEPTH
COMPENSATION INSURANCE ADDRESS, 43 4J
( p e work involved by LOCALITY MANHOLE REFERENCE
This section need not be completed if the the .. --r- '7 6) i 5� uPPEER
permit is for one hundred dollars ($100)or less.) '
NEAREST TYPE OF CO N LENGTH FROM
I certify that in the performance of the work for which this CROSS ST Y CURB P.I. M.L.TO P.L.
permit is issued, I shall not employ any person in any manner �✓ P.r_.No.
so as to become subject to the Workers'Compensation Laws. OWNER [ �;„ (�,/'!�T �t(y CO IMP.No, JOB NO
MAIL ✓'% TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS Jr
NOTICE TO APPLICANT: If, after making this Certificate of CITY L.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 i NO.OF BLDGS PERMIT
a
I hereby affirm that I am licensed under provisions of Chapter SIZE OF LOT NOW ON LOT
USE OFIF
9 (commencing with Section 7000) of Division 3 of the Busi- Buuowc5 Ee-t-ez.Ld ,.% CHARGES
ness and Professions Code, and my license is in full force and
effect, '�y�fJ�i CO „„,�. .�.,_„W,. �s', + CONNECTION CHARGE FEE. }
License N;f?n l7e-13 Lic.Class_ ADDRESS ,!•..� � I BURSEMENT FEE O
C t CtCL
9Date DISTRICT NO. GROUP MAP CESSED BY u
BK PG / Z
❑ I am exempt under e.- of the L.A.Co. iieENSE NO. ., LIC 3K
'.O' �� O
.
Plumbing Code andNODESCRIPTION WORK FEE
./or Sec. of the FINAL
HOUSE SEWER CONNECTING TO p DATE Y,.'`8 VALIDA QN CL
PUBLIC SEWER JJ
B. $ P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR ` Z
PITS AND/OR DRAINFIELD FINAL /
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM L F
Signature CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVER SEEPAGE PIT,DRAINFIELD
I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE ► r
7, A
Law for the following reason (Becton 7031.5, BUI$ness and Pro- ALTER,REPAIR OR ABANDON HOUSE no
fessions Code): SEWER OR DISPOSAL SYSTEM
I.t m ✓b # �R� V
❑ I,as owner of the property, or my employees with wages as
their sole compensation, will do the work and the structure + ^T 2 7, 5 0
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNERS Permit $ /� 2 7 v is
❑ I, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE k-7 7 ry
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO l~i, t -8 I
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY 101I 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. 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 agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
up mentioned prooperrt far inspecti n purposes.
�Ignature of Per fee �- Date SEE REVERSE FOR EXPLANATORY LANGUAGE