HomeMy Public PortalAbout5726 RIO HONDO AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
hereby affi m that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or 76A642D �S
a certified c y,0h of Sec ;"tab C),_.a E e00(REV.8/811
PoIjI�X , �- ���o�,fiv � �� ,� ���,�_� �a APPLICATION FOR PERMIT
❑ tified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
Ef Certified.,copy is filed with the cou ty building it spection COUNTY OF LOS ANGELES BUILDING AND SAFETY
de
Date_ �' plicant FOR APPLICANT TO FILL IN CONNECTION DATA
CER
KATE OF EXEMPTION FROM WORKERS' BUILDING y _ —.41_ '; stnnoN r DEPTH
COMPENSATION INSURANCE ADDRESSa T1 9
UPPER' '
(This section need not be completed if the work involved by the LocnutY _ MANHOLE REFERENCE t-j 7 j� ^- t �5 t- R
permit is for one hundred dollars ($100)or less.)
NEAREST r f' TYPE OF CO.W>rlEt'I'P�nJ LENGTH FROM
I certify that in the performance of the work for which this CROSS ST :- 4 - ' Y CURB P . M.L TOP L.
permit is issued, I shall not employ any person in any manner
P.C.No.
so as to become subject to the Workers' Compensation Laws. OWNER ' ¢' dd t .'� co.IMP.No. OB No.
MAIL
^1'° y ..��, -�': 1 / .. �+ TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant_ ADDRE - � '�'��` �"
NOTICE TO APPLICANT: If, after making this Certificate ofC ) r ,�;rE�t ? AFFIDAVIT WAIVER EASEMENT RECORD IN5TR NO DATE
Exemption, you should become subject to the Workers' L 7i�"
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT STATE ENCROACHMENT �, � ,• .: - �.-{,•
LICENSED CONTRACTORS DECLARATION tyo.of BLDGS.
/
I hereby affirm that I am licensed under provisions of Chapter SIZE OF LOT NOW ON LOT ?/'
USE OF
9 (commencing with Section 7000) of Division 3 of the Busi- 1.DINGS :' ;` CHARGES
ness I
and Professions Code, and my license Is n full force and
effect.
m CONTRACTOR; ,�. r t CONNECTION CHARGE FEE >
LiCen'ge IVU : EO Lic.Class �� ADDRESS y .'EIL
IMBUR$EMENT FEE O
ntr CiiSrt ...f-` f' '' Date - T. ..}. � y'7 '� L.ti $ "� ` ,9�'' -_�
DISTRICT NO. GROUP MAP P PROCESSED BY
I V
fir^ ,., �n BK G Z
ti ,.y.. - f
❑ I am exempt under Sec.— of the L.A. o.
STATE
c NSE NO. CLASS - "_ F
V
Plumbing Code and/or Sec. _of the NO. DESCRIPTION OF WORK FEE FINAL
TEVALIDA N LU
HOUSE SEWER CONNECTING TO "1 +`I DATE ,,..
PUBLIC SEWER 9 J.t-
B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD /
Date - HOUSE SEWER CONNECTING TO
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
❑ I,as owner of the property,or my employees with wages asi
their sole compensation, will do the work and the structure b C (1
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S I Permit $ ( o a 2 7 , i. ,
❑ I, as owner of the property,cam exclusively contracting with AUTHORIZATION I TOTAL FEE "t 3 s •.r, 2 7 %0
licensed contractors to construct the ( 7044
(Section ect j
roecton , A, 1 44
p I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO � ., C.:
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. 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 representativIS of this,County to enter
upon bezS5Cc/ mentioned property for insptrCtion purposes.
ignature of P rmittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE.